- Can be substituted for warfarin in many instances and do not require bridging prior to becoming therapeutic unless oral intake is precluded (discuss with pharmacy).
- NOT approved in the setting of mechanical heart valves—per RE-ALIGN, rates of bleeding and thromboembolism are higher with dabigatran than warfarin.
- Do NOT use in patients with antiphospholipid syndrome (less effective than warfarin).
- Generally contraindicated in patients with end-stage renal disease.
- Rivaroxaban and apixaban now often used in patients with non-GI cancers.
- Check with pharmacy about possible drug interactions.
Initiation: Dabigatran (Pradaxa®)
Indication |
Renal Function (CrCl mL/min) |
Recommended Dose |
Transition from parenteral |
Reversal |
---|---|---|---|---|
Non-valvular atrial fibrillation |
>30 |
150 mg po twice daily |
Start DOAC at least 2 hours before turning off drip OR two hours before next dose |
Dialysis Idarucizumab
|
15-30 |
75 mg po twice daily |
|||
<15 or dialysis |
Avoid use |
|||
Treatment of DVT/PE |
>30 |
150 mg po twice daily after 5-10 days of parenteral therapy with UFH/LMWH |
||
<30 or dialysis |
Avoid use |
Initiation: Rivaroxaban (Xarelto®)
Indication |
Renal Function (CrCl mL/min) |
Recommended Dose |
Transition from parenteral |
Reversal |
---|---|---|---|---|
Non-valvular atrial fibrillation |
>30 |
20 mg po daily with evening meal |
Start DOAC within 2 hours prior to next dose of LMWH or immediately after stopping heparin gtt |
Not amenable to dialysis Andexanet alfa for life-threatening bleed
If Andexanet alfa not available, administer 4-factor PCC (off-label) |
15-30 |
15 mg po once daily with evening meal |
|||
<15 |
Avoid use |
|||
Treatment of DVT/PE |
≥30 |
15 mg twice daily with food for 21 days, then 20 mg once daily with food |
||
<30 |
Avoid use |
|||
Knee replacement |
≥30 |
10 mg once daily for 12-14 days |
||
|
<30 |
Avoid use |
||
Hip replacement |
≥30 |
10 mg once daily for 35 days |
||
|
<30 |
Avoid use |
Initiation: Apixaban (Eliquis®)
Indication |
Recommended Dose |
Dose Adjustments |
Transition from parenteral |
Reversal |
---|---|---|---|---|
Non-valvular atrial fibrillation |
5 mg twice daily |
2.5 mg twice daily if any 2 of the following:
|
Start DOAC at the time of next scheduled dose of LMWH or immediately after stopping heparin gtt
|
Not amenable to dialysis Andexanet alfa for life-threatening bleed
If Andexanet alfa not available, administer 4-factor PCC (off-label) |
Treatment DVT/PE |
10 mg twice daily x 7 days followed by 5 mg twice daily |
|||
Prophylaxis after TKA/THA |
2.5 mg twice daily |
TKA 12 days, THA 35 days |
Reversal
- Discontinue drug. DOACs have relatively short half-lives (generally 8-17 hours).
- If <2 hours since administration/ingestion, administer activated charcoal.
- If dabigatran, and dialysis access is feasible, consider hemodialysis.
- If patient is on concurrent antiplatelet therapy, consider STAT platelet transfusion (one unit for aspirin or dipyridamole, two units for more potent agents).
- FFP and/or cryoprecipitate are NOT recommended due to unclear efficacy and large volume.
- Contraindications to PCCs include DIC and HIT. PCCs raise thrombotic risk and should be used with caution if history of VTE in past 6 weeks. Consider their use only when other measures fail.
UCSF guidelines for the reversal of major bleeding to TSOACs in adults, UCSF Comprehensive Hemostasis and Antithrombotic Service 2013.
Eikelboom JW et al. Dabigatran vs warfarin in patients with mechanical heart valves. N Engl J Med 2013; 369:1206-1214