![]() ![]() The number of patients receiving treatment with direct oral anticoagulants (DOACs) is increasing, as clinical trials have demonstrated non-inferiority or superiority in terms of prevention and treatment of thrombo-embolic events compared with vitamin K antagonists (VKAs). This review aims to provide a systematic approach to managing patients on DOACs, based on recent updates of various perioperative guidance, and highlighting the advantages and limits of recommendations based on pharmacokinetic properties and laboratory tests. ![]() Furthermore, recent publications have highlighted the potential danger of heparin bridging use when DOACs are stopped before an invasive procedure.Īs antidotes are progressively becoming available to manage severe bleeding or urgent procedures in patients on DOACs, accurate laboratory tests have become the standard to guide their administration and their actions need to be well understood by clinicians. The high inter-patient variability of DOAC plasma levels has challenged the traditional recommendation that perioperative DOAC interruption should be based only on the elimination half-life of DOACs, especially before invasive procedures carrying a high risk of bleeding. The perioperative guidelines have undergone numerous updates as clinical experience of emergency management has increased and perioperative studies including measurement of residual anticoagulant levels have been published. Each year, 10–15% of patients on oral anticoagulants will undergo an invasive procedure and expert groups have issued several guidelines on perioperative management in such situations. Because fatal reactions, often resembling anaphylaxis, have been reported with protamine sulfate, it should be given only when resuscitation equipment and treatment of anaphylactic shock are readily available.Direct oral anticoagulants (DOACs) have been licensed worldwide for several years for various indications. Administration of protamine sulfate can cause severe hypotensive and anaphylactoid reactions. Particular care should be taken to avoid overdosage with protamine sulfate. Neutralization of enoxaparin by protamine Time Since LOVENOX DoseĪ second infusion of 0.5 mg protamine per 1 mg LOVENOX may be administered if the aPTT measured 2 to 4 hours after the first infusion remains prolonged. Attending physicians confronted with a potential overdosage of enoxaparin should always use their best clinical judgment in determining the appropriate dosing regimen of protamine to be administered. In the event that prompt reversal of the anticoagulant effects of enoxaparin is required at any time after LOVENOX dosing, the following table is provided as a guide for initial use of protamine. ![]() Anti-factor Xa activity is never completely neutralized (maximum about 60%). However, even with higher doses of protamine, the aPTT may remain prolonged to a greater extent than usually seen with unfractionated heparin. This effect may be largely neutralized by slow intravenous injection of protamine sulfate. ![]() The anticoagulant effect of LOVENOX is inhibited by protamine. In more serious cases, protamine should be administered. LOVENOX should be immediately discontinued, at least temporarily, in cases of significant excess dosage. Accidental overdosage following administration of LOVENOX (enoxaparin) may lead to hemorrhagic complications. ![]()
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