| Weight <= 100 kg or INR <= 6 | Weight > 100 kg or INR > 6 | |
|---|---|---|
| No CNS Bleed* | 1500 units | 2000 units |
| CNS Bleed | 2000 units | 2500 units |
| Give all Kcentra doses with phytonadione 10 mg IVPB over 30 minutes. Repeat INR in 30 minutes after Kcentra | ||
*life-threatening GI bleed, retroperitoneal bleed, fall in Hg >= 2 g/dl or Hg <= 8 g/dl if no baseline
| Agent | Kcentra Dose |
|---|---|
| Apixaban | 25-50 units/kg (max 5000 units) or 2000 units fixed dose |
| Rivaroxaban | |
| Edoxaban | |
| Betrixaban | |
| Dabigatran | 50 units/kg (max 5000 units) |
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Only use a reversal agent for patients with life-threatening DOAC-associated bleeding into a critcal organ, or when bleeding is not controlled with maximal supportive measures and there is a demonstration or reasonable expectaion that the patient has clinically relevant plasma DOAC levels.
For dabigatran-associated major bleeding in whom a reversal agent is warranted, suggest idarucizumab 5 g IV. If idarucizumab is not available, treat with FEIBA 50 units/kg IV.
In patients with rivaroxaban-associated or apixaban-associated major bleeding in whom a reversal agent is warranted, suggest Andexxa and if Andexxa is unavailable suggest Kcentra 2000 units. In patients with edoxaban-asscociated or betrixaban-associated major bleeding in whom a reversal agent is warranted, suggest high dose Andexxa or Kcentra 2000 units.
In DOAC-treated patients who require an invasive procedure, suggest that a reversal agent be administered only if the procedure cannot be safely performed while the patient is anticoagulated, cannot be delayed, and there is demonstration or reasonable expectation that the patient has clinically relevant plasma DOAC levels.
In dabigatran-treated patients who require an urgent procedure and in whom a reversal agent is warranted, suggest treatment with idarucizumab 5 g IV or if unavailable suggest FEIBA 50 units/kg IV.
In factor Xa inhibitor-treated patients who require an urgent procedure and in whom a reversal agent is warranted suggest treatment with Andexxa or if unavailable suggest Kcentra 2000 units.
In patients with DOAC overdose without bleeding, suggest against the routine use of reversal agents.
In DOAC-treated patients who present with trauma without bleeding, suggest against the routine use of reversal agents.