Direct new oral
anticoagulants (NOACs) - inhibitors of
thrombin or factor Xa - are intended to be used largely in the treatment of venous thromboembolic disease or the prevention of systematic
embolism in
atrial fibrillation, instead of
vitamin K antagonists. Like any
anticoagulant treatment, they are associated with spontaneous or provoked haemorrhagic risk. Furthermore, a significant proportion of treated patients are likely to be exposed to emergency surgery or invasive procedures. Given the absence of a specific
antidote, the action to be taken in these situations must be defined. The lack of data means that it is only possible to issue proposals rather than recommendations, which will evolve according to accumulated experience. The proposals presented here apply to
dabigatran (
Pradaxa(®)) and
rivaroxaban (
Xarelto(®)); data for
apixaban and
edoxaban are still scarce. For urgent surgery with haemorrhagic risk, the
drug plasma concentration should be less or equal to 30ng/mL for
dabigatran and
rivaroxaban should enable surgery associated with a high
bleeding risk. Beyond that, if possible, the intervention should be postponed by monitoring the
drug concentration. The course to follow is then defined according to the
NOAC and its concentration. If the
anticoagulant dosage is not immediately available, worse propositions, based on the usual tests (prothrombin time and activated partial thromboplastin time), are presented. However, these tests do not really assess
drug concentration or the risk of
bleeding that depends on it. In case of serious
bleeding in a critical organ, the effect of
anticoagulant therapy should be reduced using a non-specific procoagulant
drug as a first-line approach: activated
prothrombin complex concentrate (aPCC) (
FEIBA(®) 30-50U/kg) or non-activated PCC (50U/kg). In addition, for any other type of severe haemorrhage, the administration of a procoagulant
drug, which is potentially thrombogenic in these patients, is discussed according to the
NOAC concentration and the possibilities of mechanical haemostasis.