Reversal Information

• Repeat monitoring tests for anticoagulant and platelets, PT, PTT, and fibrinogen after infusing a reversal agent and q 4-6 hours until severe bleeding risk has passed. Determine if and when anticoagulation should be reinitiated and what agent. Monitor patient for thrombosis and bleeding.
• Idarucizumab is FDA indicated for reversal of dabigatran. It is recommended for life-threatening bleeding, bleeding into a critical organ, or prior to an emergency procedure.
• The recommended Adult dose is:  Idarucizumab 5 g IV per dose administered as 2 separate 2.5 g doses no more than 15 minutes apart. Pediatric dosing of Idarucizumab is NOT available. Idarucizumab is on formulary at St. Vincent.
• Critical site bleeds: Intracranial hemorrhage, including intraparenchymal, subdural, epidural, and subarachnoid hemorrhages; Other CNS hemorrhage, including intraocular, intra- or extra-axial spinal hemorrhages; Pericardial tamponade; Airway, including posterior epistaxis; Hemothorax, intraabdominal bleeding, and retroperitoneal hemorrhage; Extremity bleeds, including intramuscular and intraarticular bleeding concerning for compartment syndrome, bleeding associated with hemodynamic instability, bleeding in a noncompressible vessel (e.g., subclavian)
• If idracuzumab isn’t available, then consider Kcentra (prothrombin complex concentrate) 25-50 units/kg for severe bleeding or NovoSeven (rFVIIa) 90 mcg/kg. FEIBA (activated PCC) 50 units/kg would be a last resort due to higher thrombosis risk. They are on formulary at PMCH but are not labeled by the manufacturer for reversal of rivaroxaban.
• In the setting of overdose, also consider administration of activated charcoal (50 g) if within 2 hours of dose.
• Dabigatran is dialyzable.