1. Anticoagulants and reversal

2. Warfarin Reversal There are guidelines. Look them up each time
INR <4.5 without bleed
Reduce or omit next dose
INR without bleed
Withold warfarin
1-2mg vit K orally
Repeat INR in hours
INR >10 without bleed
Vit K 3-5mg oral/IV
Consider PCC if high risk
Repeat INR hours

3. Bleeding Major bleed, INR >1.5 Significant bleed and INR >2
Intracranial, spinal, life threatening
PCC 50iu/kg
mL FFP (15mL/kg if PCC unavailable)
Vit K 5-10mg IV
Significant bleed and INR >2
PCC 35-50iu/KG dependent on INR
Minor bleed
1 unit FFP
Vit K 1-2mg orally or 0.51mg IV if INR >4.5 or bleeding risk high

4. Vitamin K Slow – several hours to take effect
Don’t give more than you need – makes restarting warfarin very difficult
Don’t give IM

5. Fresh frozen plasma Acute reversal in active bleeding
Dose is 1 unit if PCC used, 4 units if not (to start)
Has native INR 1.5
Does not fully replace factor IX
Has factor VII which Prothrombinex does not
Slow to get
Large volume

6. Prothrombin complex concentrate
Freeze dried factors II, IX, X
Very small amount of factor VII
PCC and FFP together will reverse warfarin in ~15 minutes
Target INR
Current INR
Dose (IUnits/kg)
Normalisation 30 35
≥ 3.6 50 15 25
>10 40
Dose calculator

7. Dabigatran Direct thrombin inhibitor
Behaves like a drug
T ½ hours, longer in renal failure
APTT best for measurement – OK if normal
Reversal – ??
PCC does not seem to work
aPCC (FEIBA) might be better – but we don’t have any
Can be dialysed

8. Rivaroxaban/Apixaban
Factor X antagonist
Also like a drug
T1/ hours – more with rivaroxaban in renal failure.
APTT and PT prolonged
Reversal with PCC – 50iu/kg, weak evidence.
Protein bound, cannot be dialysed

9. NOACS and Coags Parameter Apixaban Dabigatran Rivaroxaban PT Prolonged
No effect
APTT
Prolonged ( times normal for therapeutic levels)
Prolonged ( times control)
Thrombin time
INR
Not useful