Direct oral anticoagulants and the management of bleeding

Venous and arterial thromboembolism are a major health burden worldwide and oral anticoagulation is fundamental in treating and preventing many thrombotic disorders. Direct oral anticoagulants (DOACs) have replaced traditional vitamin K antagonists for many indications for oral anticoagulation. Large Phase III studies and meta-analyses have shown that the risk of intracranial and fatal bleeding with DOACs is lower than with vitamin K antagonists. Despite this, when DOACs were first approved there was hesitancy among clinicians to prescribe them because of challenges in managing major bleeding, leading to the development and approval of two DOAC-specific reversal agents. Clear protocols ensuring the swift recognition and treatment of patients bleeding on DOACs, along with access to specific reversal agents and coagulation factors, improves patient outcomes.