When should reversal agents be used in cases of severe and life-threatening bleeding?
Reversal agents should be used sparingly in the cases of severe and life-threatening bleeding, which includes bleeding causing hemodynamic compromise, ICH, bleeding into a critical organ or closed space, persistent bleeding despite general supportive measures and local hemostatic support, or risk of recurrent bleeding due to excess NOAC drug exposure due to delayed clearance of NOAC (eg, acute renal failure) or overdose. In a patient with serious bleeding, a specific reversal agent (where available) should be used instead. General hemostatic agents as nonspecific agents are less effective in reversing coagulation abnormalities, have not been shown to improve outcomes, and are potentially prothrombotic. Although coagulation testing will identify those patients with therapeutic levels of anticoagulation who will likely benefit from specific reversal agents, and helps physicians to monitor the response to reversal, it is reasonable to administer specific reversal agents immediately without waiting for a laboratory test confirming therapeutic levels of anticoagulation in patients who present with life-threatening bleeding presumed to be on an NOAC. 