Anticoagulation Reversal

Products

3-factor PCC

• Factors II, IX, and X
• Time to reversal: Minutes

4-factor PCC

• Factors II, IX, X, and VII
• Time to reversal: Minutes

Cryoprecipitate

• Factors VIII, XIII, vWF
• 10-20 mL total volume
• 150-250 mg fibrinogen (greater concentration than FFP)
• More expensive

Fresh Frozen Plasma (FFP)

• All coagulation factors
• 250-300 mL total volume
• 700-800 mg of fibrinogen
• Time to reversal: Generally within a couple hours

Vitamin K

• Time to reversal:
  • Oral: 12-24 hours
  • IV: ~6 hours

Indications for patients with major/serious bleed

Warfarin reversal

• Vitamin K
• Add 4-Factor PCC for more rapid reversal
  • FFP can substitute if PCC not available

DOAC reversal

• Unactivated PCC vs Activated PCC
  • Activated PCC: FEIBA (Factor Eight Bypassing Activity)
• Specific reversal agents
  • Dabigatran – Idarucizumab
  • Factor Xa inhibitors (rivaroxaban, apixaban) – Andexanet alpha

Liver disease

• Vitamin K
• Cryoprecipitate if fibrinogen < 100 (or if awaiting results and bleeding uncontrolled)
• Avoid FFP if possible due to large-volume nature and its negative effect on portal venous pressures. Can consider using if bleeding persists after fibrinogen repletion with Cryoprecipitate