How I Treat How I treat target-specific oral anticoagulant–associated bleeding

Target-specific oral anticoagulants (TSOACs) that target thrombin (dabigatran) or factor Xa (rivaroxaban and apixaban) offer practical advantages over vitamin K antagonists (VKAs) for long-term oral anticoagulant therapy, including rapid onset of action, short halflives, fewer drug and food interactions, and predictable pharmacokinetics eliminating the need for routine monitoring of anticoagulant effect. In large clinical trials, these agents demonstrated similar or enhanced efficacy and/or safety compared with VKAs and lowmolecular-weight heparin (LMWH) for prevention and treatment of thromboembolism. Table 1 outlines currently approved indications for clinical use of TSOACs. Unlike VKAs for which vitamin K and coagulation factor replacement (with either prothrombin complex concentrate [PCC] or plasma) can be used in case of bleeding, there are no therapies that specifically reverse the anticoagulant effect of the TSOACs. Management of TSOAC-associated bleeding is further complicated by the difficulty in determining the degree of anticoagulant effect present at the time of the bleed.Widely available tests of the integrity of the coagulation cascade are variably responsive to the effect of the TSOACs (and in many cases, may fall within the normal range even when therapeutic drug levels are present), and specific tests (although available) are largely limited to highly specialized coagulation laboratories. In this narrative review, we discuss available evidence for reversal strategies and provide a practical approach to the management of TSOAC-associated bleeding.