Newly Published
Clinical Focus Review  |   March 2020
Assessing and Reversing the Effect of Direct Oral Anticoagulants on Coagulation
Author Notes
  • From the Division of Hematology, Brigham and Women’s Hospital, Boston, Massachusetts (A.L., J.M.C.); and Harvard Medical School, Boston, Massachusetts (A.L., J.M.C.).
  • Submitted for publication November 1, 2019. Accepted for publication February 26, 2020.
    Submitted for publication November 1, 2019. Accepted for publication February 26, 2020.×
  • Correspondence Address correspondence to Dr. Connors: Brigham and Women’s Hospital, Harvard Medical School, 75 Francis Street, Boston, Massachusetts 02115. jconnors@bwh.harvard.edu. Information on purchasing reprints may be found at www.anesthesiology.org or on the masthead page at the beginning of this issue. Anesthesiology’s articles are made freely accessible to all readers, for personal use only, 6 months from the cover date of the issue.
Article Information
Coagulation and Transfusion / Clinical Focus Review
Clinical Focus Review   |   March 2020
Assessing and Reversing the Effect of Direct Oral Anticoagulants on Coagulation
Anesthesiology Newly Published on March 25, 2020. doi:https://doi.org/10.1097/ALN.0000000000003268
Anesthesiology Newly Published on March 25, 2020. doi:https://doi.org/10.1097/ALN.0000000000003268
Direct oral anticoagulants have improved anticoagulation options for many patients, but they present challenges regarding monitoring and reversal of anticoagulant activity. Anesthesiologists are likely to encounter patients taking direct oral anticoagulants in a variety of clinical settings including scheduled procedures, emergency procedures, trauma, and critical care units. This review focuses on the pharmacokinetics of direct oral anticoagulants, testing methods to assess anticoagulant activity, and the use of reversal agents, to give the practicing anesthesiologist the necessary knowledge to manage situations encountered in clinical practice.
The direct oral anticoagulants are approved and prescribed for a number of indications to prevent and treat thromboembolic disease. Large phase III randomized controlled trials comparing direct oral anticoagulants to either vitamin K antagonists or low-molecular-weight heparin have demonstrated similar or better safety and efficacy for many indications. The direct thrombin inhibitor dabigatran and the Xa inhibitors apixaban, rivaroxaban, and edoxaban have been approved by the U.S. Food and Drug Administration and European Medicines Agency for treatment of venous thromboembolism and prevention of stroke in nonvalvular atrial fibrillation.1–4  Dabigatran, apixaban, and rivaroxaban are approved for venous thromboembolic prophylaxis after hip and knee replacement surgery.1–3  Rivaroxaban and apixaban are approved for extended venous thromboembolic prophylaxis.2,3  Rivaroxaban and an additional Xa inhibitor, betrixaban, are Food and Drug Administration–approved for extended venous thromboembolic prophylaxis in medically ill, hospitalized patients.2,5  Low-dose rivaroxaban at 2.5 mg twice daily in combination with low-dose aspirin has been approved by the Food and Drug Administration to reduce the risk of cardiovascular death, myocardial infarction, and stroke in patients with chronic coronary artery disease or peripheral artery disease.2