What Happens When Anticoagulation Therapy Needs to Be Stopped?

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The MD Magazine Peer Exchange “Novel Anticoagulation Options: Target-Specific Oral Agents and Their Antidotes” features leading physician specialists discussing key topics in anticoagulation therapy, including the clinical characteristics of current and emerging agents and criteria for use in specific patient populations.

This Peer Exchange is moderated by Peter Salgo, MD, professor of medicine and anesthesiology at Columbia University and an associate director of surgical intensive care at the New York-Presbyterian Hospital in New York City.

The panelists are:

• Scott Kaatz, DO, MSc, Chief Quality Officer at Hurley Medical Center in Flint, Michigan, and clinical associate professor at Michigan State University
• Seth Bilazarian, MD, clinical and interventional cardiologist at Pentucket Medical and instructor of medicine at Harvard Medical School
• Gerald Naccarelli, MD, Bernard Trabin Chair in Cardiology, professor of medicine and chief of the Division of Cardiology at Penn State University School of Medicine, and associate clinical director at Penn State Heart and Vascular Institute in Hershey, Pennsylvania
• Christian T. Ruff, MD, associate physician in the cardiovascular medicine division at Brigham and Women’s Hospital, and assistant professor of medicine at Harvard Medical School in Boston

Any number of elective procedures, such as a colonoscopy or skin resection for a mole, could require stopping the anticoagulant therapy. At that point, the creatinine should be assessed. Discontinuation could also be needed when patients are bleeding from trauma or other emergency situations.

Even for warfarin, Naccarelli said that vitamin K plays a limited role in reversing the anticoagulation. It may take 12 to 16 hours for the direction to change, but vitamin K will not work in emergency situations. They are more likely to be given fresh frozen plasma. Ruff added that warfarin is not reversible; vitamin K simply allows the liver to produce more vitamin K dependent clotting factors that eventually help clotting, which takes time.

If you think about it in a different way, though, said Ruff, you could use warfarin because it theoretically has a reversal agent, even though it does not, but warfarin causes twice as much serious bleeding as the newer agents, so then you have to hope that reversal will work if you need it. What would be better is to prevent the bleeding from happening in the first place.

The panel said it was important to note that reversal of warfarin should not be initiated for more minor bleeding events, because it will be difficult to restart the anticoagulant after that, and then the patient will be exposed unnecessarily to a thrombotic event. Naccarelli tells his patients to call him if they have bleeding while on one of the novel oral anticoagulants, and not to take the next dose while they are reaching out to him, because stopping the drug starts to reverse the effects of the drug as quickly as vitamin K does for warfarin.