Anticoagulation is key to the treatment/prevention of thromboembolic events. The primary complication of anticoagulation is serious or life-threatening
hemorrhage, which may necessitate prompt
anticoagulation reversal; this could also be required for nonbleeding patients requiring urgent/emergent invasive procedures. The decision to reverse anticoagulation should weigh the benefit-risk ratio of supporting hemostasis versus post-reversal
thrombosis. We appraise the available guidelines/recommendations for
vitamin K antagonist (VKA) and direct oral
anticoagulant (DOAC) reversal in the management of major
bleeding, and also assess recent clinical data that may not yet be reflected in official guidance. In general, available guidelines are consistent in their recommendations, advocating administration of
vitamin K and 4-factor
prothrombin complex concentrates (4F-PCCs) rather than fresh frozen plasma to patients with VKA-associated
intracranial hemorrhage and life-threatening
bleeding, and specific reversal agents as essential
therapy for DOAC reversal in those same severe conditions. However, guidelines also recommend
off-label use of PCCs for DOAC reversal when specific reversal agents are unavailable. Limited recent evidence generally support the latter recommendation, but guidelines are likely to evolve as more data become available.