Management of Bleeding Complications in Patients Taking Direct Oral Anticoagulants at a Large Tertiary Academic Medical Center

Direct oral anticoagulants (DOACs) offer a fixed-dose alternative to warfarin for stroke prevention in patients with atrial fibrillation. However, there is minimal evidence to guide the management of bleeding in patients taking a DOAC. We retrospectively evaluated the acute management of major bleeding in this patient population at a large, tertiary academic medical center. We evaluated various strategies of management including dialysis, transfusions, pharmacologic agents, surgical intervention, and reinitiation of anticoagulation. We also assessed length of intensive care unit and hospital stay, mortality, and laboratory markers for coagulation. Thirteen patients were included in this analysis; ten patients were taking dabigatran; and three were taking rivaroxaban. Eight patients were treated for gastrointestinal bleeding; four for subarachnoid hemorrhage; and one for a retroperitoneal bleed. No patients received concentrated coagulation factors; five received packed red blood cells; two received packed red blood cells and platelets; one received fresh frozen plasma; and one received fresh frozen plasma and packed red blood cells. No patients required dialysis and two patients who experienced subarachnoid hemorrhages needed surgical interventions. The average hematocrit on presentation was 29.1 +/- 6.8 % and was 33.7 +/- 3.7 % 3 days after presentation. Therapeutic anticoagulation was restarted during admission on six patients; two were restarted on their original anticoagulant, while four received an alternative agent. Patients treated for a non-intracranial major bleed while taking a DOAC at our institution have been managed with supportive care alone without the need for concentrated coagulation factors.