When should a specific reversal agent be used instead of general hemostatic agents in the case of severe and life-threatening bleeding?
A specific reversal agent should be used instead of general hemostatic agents in the case of severe and life-threatening bleeding such as 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. 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.