Reversal strategies for different anticoagulants
| Anticoagulant type . | Target . | Half-life, h . | Route of elimination . | Reversal strategy . | Laboratory investigation . |
|---|---|---|---|---|---|
| Vitamin K antagonists | Vitamin K–dependent coagulation factors | 20-60 (warfarin) | Liver metabolism; metabolites primarily eliminated in the urine (warfarin) | Vitamin K, PCC, plasma | INR |
| UFH | Antithrombin, factor IIa, factor Xa | 1-2 | Therapeutic dose: nonrenal elimination; very high doses: possible renal contribution | Protamine sulfate | aPTT |
| LMWH | Factor Xa | 3-7 | Renal | Protamine sulfate: partial reversal; rFVIIa: life-threatening bleeding | Chromogenic anti-Xa assay |
| Fondaparinux | Factor Xa | 17-21 | Renal | rFVIIa (high dose, 90 mcg/kg): life-threatening bleeding | Chromogenic anti-Xa assay |
| Dabigatran | Factor IIa | 12-17 | Renal (80%) | Idarucizumab, aPCC | aPTT (if normal, it excludes above on-therapy dabigatran levels but does not exclude the therapeutic range; TT (if normal, it excludes the presence of dabigatran); dTT; ECA |
| Apixaban | Factor Xa | 8-15 | Renal (25%) | 4F-PCC, andexanet alfa | Chromogenic anti-Xa assay |
| Betrixaban | Factor Xa | 19-27 | Renal (11%) | 4F-PCC, andexanet alfa | Chromogenic anti-Xa assay |
| Edoxaban | Factor Xa | 9-11 | Renal (35%) | 4F-PCC, andexanet alfa | PT (may be elevated, although a normal PT does not exclude clinically relevant levels); chromogenic anti-Xa assay |
| Rivaroxaban | Factor Xa | 9-13 | Renal (66%) | 4F-PCC, andexanet alfa | PT (may be elevated, although a normal PT does not exclude clinically relevant levels); chromogenic anti-Xa assay |
| Anticoagulant type . | Target . | Half-life, h . | Route of elimination . | Reversal strategy . | Laboratory investigation . |
|---|---|---|---|---|---|
| Vitamin K antagonists | Vitamin K–dependent coagulation factors | 20-60 (warfarin) | Liver metabolism; metabolites primarily eliminated in the urine (warfarin) | Vitamin K, PCC, plasma | INR |
| UFH | Antithrombin, factor IIa, factor Xa | 1-2 | Therapeutic dose: nonrenal elimination; very high doses: possible renal contribution | Protamine sulfate | aPTT |
| LMWH | Factor Xa | 3-7 | Renal | Protamine sulfate: partial reversal; rFVIIa: life-threatening bleeding | Chromogenic anti-Xa assay |
| Fondaparinux | Factor Xa | 17-21 | Renal | rFVIIa (high dose, 90 mcg/kg): life-threatening bleeding | Chromogenic anti-Xa assay |
| Dabigatran | Factor IIa | 12-17 | Renal (80%) | Idarucizumab, aPCC | aPTT (if normal, it excludes above on-therapy dabigatran levels but does not exclude the therapeutic range; TT (if normal, it excludes the presence of dabigatran); dTT; ECA |
| Apixaban | Factor Xa | 8-15 | Renal (25%) | 4F-PCC, andexanet alfa | Chromogenic anti-Xa assay |
| Betrixaban | Factor Xa | 19-27 | Renal (11%) | 4F-PCC, andexanet alfa | Chromogenic anti-Xa assay |
| Edoxaban | Factor Xa | 9-11 | Renal (35%) | 4F-PCC, andexanet alfa | PT (may be elevated, although a normal PT does not exclude clinically relevant levels); chromogenic anti-Xa assay |
| Rivaroxaban | Factor Xa | 9-13 | Renal (66%) | 4F-PCC, andexanet alfa | PT (may be elevated, although a normal PT does not exclude clinically relevant levels); chromogenic anti-Xa assay |
dTT: dilute thrombin time; ECA: ecarin chromogenic assay; 4F-PCC, 4 factor prothrombin complex concentrate.