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Management of Anticoagulant-Associated Bleeding Events Including Reversal Strategies

Background: Healthcare staff involved in anticoagulant-associated bleeding management, including providers, nurses and pharmacists, should be

familiar with available reversal agents and procoagulant therapies, including: Which anticoagulants they will (and will not) reverse Brand and generic names Dosing

Additionally, given high cost and potential for adverse events of some reversal strategies, all healthcare staff should share in stewardship of anticoagulant reversal, including judicious use of reversal agents, to optimize use and patient outcomes

Rationale: This template was created by the Anticoagulation Forum to aid healthcare institutions in achieving compliance with The Joint

Commission National Patient Safety Goal 03.05.01 Element of Performance 2 pertaining to reversal of anticoagulation and management of bleeding events related to each anticoagulant medication1

The Anticoagulation Forum developed this clinical tool, which can be modified by individual organizations based on local resources, formularies and agreed-upon approaches

This template is intended as an institutional aid and should not replace sound clinical judgment. The Anticoagulation Forum assumes no medical or legal liability for final versions created by individual organizations

Scope: Management of clinically significant bleeding (i.e., requiring intervention) in patients on anticoagulant therapy who present to or are

admitted to the hospital It does not include guidance for:

Reversal of anticoagulation for surgical or procedural interventions Mild or nuisance bleeding (e.g., bruising, hemorrhoidal, mild nosebleed) Asymptomatic elevated INRs in patients on warfarin

Resource contact information: (list entities most appropriate to your institution) Critical care intensivist on-call X-XXXX Central Pharmacy X-XXXX Unit pharmacist X-XXXX Blood bank X-XXXX

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Universal Principles and InformationRisk vs. benefitof anticoagulation reversal in bleeding

Anticoagulation reversal strategies should be limited to serious bleeding where the immediate need for anticoagulant reversal outweighs the risk of thrombosis (either from the reversal agent itself or normalization of coagulation in a patient with underlying thromboembolic risk) and only if bleeding is not controlled with maximal supportive measures.2,3

High thrombotic risk

In populations at high risk for thrombosis compared to bleeding (e.g., LVAD, mechanical heart valve, recent acute thrombotic event), consider more conservative reversal approaches whenever feasible

Mild bleeding Defined as bleeding that does not require urgent (same-day) intervention (e.g., minor nosebleed, hemorrhoidal bleeding, bruising)

Immediate reversal is typically not needed and should be avoided Simple measures should be applied, such as:

Consideration for holding anticoagulant and antiplatelet medications until mild bleeding resolves Institute local measures, as appropriate, such as application of pressure Consider use of decongestant nasal spray for nosebleeds

Impaired organ function

Elimination half-lives and duration of anticoagulant effect may be prolonged, and last for several days in the presence of organ failure or drug interactions

Neuraxial considerations

If patients have a neuraxial device (e.g., epidural catheter), monitor for signs/symptoms of spinal epidural hematoma (lower back pain, bladder incontinence, lower extremity paresthesia/paralysis)4

Prothrombin complex concentrates (PCCs)

Inactivated 4-Factor PCC (Kcentra®) contains Factors II, VII, IX, X and trace amounts of heparin (do not use in patients with active confirmed heparin-induced thrombocytopenia [HIT])

Activated 4-Factor PCC (FEIBA®) contains Factors II, VIIa, IX and X Optimal dosing strategies have not been identified If giving PCC, no need to co-administer FFP, unless volume resuscitation also desired

Adjunctive therapies

Tranexamic acid 1 gm IV x 1 for refractory bleeding DDAVP 0.3-0.4 mcg/kg x 1 for patients recently on antiplatelet therapy

Resumption ofanticoagulation

Whenever possible, anticoagulation should be resumed in a timely manner to avoid thromboembolic complications related to the underlying indication for anticoagulation.5

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Table of Contents - Hyperlinked

Warfarin............................................Page 5Dabigatran........................................Page 6Apixaban...........................................Page 7Betrixaban.........................................Page 8Edoxaban..........................................Page 9Rivaroxaban......................................Page 10Argatroban.........................................Page 11Bivalirudin..........................................Page 11Fondaparinux.....................................Page 12Unfractionated Heparin ...................Page 13Dalteparin..........................................Page 14Enoxaparin.........................................Page 15Resumption of Anticoagulation........Page 16Andexanet alfa dosing......................Page 16References.........................................Page 17

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Note: Actions and components of steps below can and should occur in tandem via multidisciplinary approaches whenever possibleSTEP 1:Patient history

Obtain essential information from appropriate persons (primary team, medical chart, patient, family, EMT, pharmacy and other sources)� Which antithrombotic agents and dose patient is suspected/confirmed to be taking (including both anticoagulants and antiplatelets)� Other medications patient is taking to assess for potential drug interactions that may be potentiating bleed� Indication for anticoagulation� Date of most recent thrombotic event (if any)� Time of last dose of anticoagulant if possible� Current renal function, hepatic function, complete blood count (CBC)

STEP 2:1. Severity of bleed

Determine A) severity of bleed, B) urgency of reversal, and C) relevant general approachesCritical Major Non-major Comments

Defined as: Intracranial, intraocular bleed or

intraspinal bleedOR Bleeding causing hemodynamic

instability SBP <90 mm Hg MAP < 65 mm Hg Orthostatic hypotension Urine output < 0.5

ml/kg/hr

Defined as: Overt bleed (e.g. GI/GU/

peritoneal)

AND Drop in Hgb >2g/ dL or

transfusion of ≥2 units RBCs

AND Not meeting definition of critical

bleeding

Defined as: Requiring medical attention

(e.g. ED visit or urgent clinic visit)

AND Not meeting definition of

critical or major bleeding

Bleed severity: Defined differently by different

organizations 3,6,7

Not always easily categorized

2. Urgency of reversal (timeframe)

Emergent(minutes)

Emergent(minutes to hours)

Semi-urgent(hours)

3. General approaches (regardless of specific anticoagulant)

□ Hold all anticoagulant and antiplatelet medications□ Institute supportive strategies as needed□ Consider transfer to intensive care unit□ Intubation, fluid resuscitation, transfusion as needed□ Notify other services as needed (e.g.- endoscopy, radiology, surgery, OR) and have them on standby□ Ongoing assessment of vital signs, coagulation parameters, other labs (e.g., Ca++, pH)□ Assess for and manage comorbidities contributing to the bleed (e.g., renal dysfunction, liver disease, thrombocytopenia)□ Identify and control source of bleed (local therapy /manual compression/ procedural or surgical intervention)

□ Consider holding anticoagulant and antiplatelet medications

□ Institute local measures as appropriate

Apply pressure and use decongestant nasal spray for nosebleeds)

STEP 3:Bleed management

Determine most appropriate management approach(es) based on specific anticoagulant(s) and severity of bleed

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Oral Anticoagulants Critical Major Non-major CommentsWarfarin(Coumadin®)

Half-life: ~40 hours

Elimination:Hepatic

Lab(s) to guide therapy:INR (baseline and q 12 hrs PRN)

Drug class:Vitamin K antagonist

1. Draw initial INR STAT

2. Hold warfarin

3. Supportive measures

4. If INR elevated, institute reversal immediately

□ Vitamin K 5-10 mg IV STAT3,8

PLUS one of the following STAT

Inactivated 4F-PCC IV STAT

Weight and INR-BASED DOSING3

(using actual body weight, max weight 100 kg, max dose 5000 units)□ INR >1.4 – 4: 25 units/kg□ INR 4.1 – 6: 35 units/kg□ INR >6: 50 units/kg

OR

FIXED DOSING3

□ 1000 units□ 1500 units□ 2000 units

4. REPEAT INR within 15-30 minutes after inactivated 4F-PCC administration

5. May give repeat inactivated PCC X1 PRN for refractory bleeding


2. Hold warfarin


4. If INR elevated, institute reversal if bleeding is not controlled with maximal supportive measures.

□ Vitamin K 2-10 mg IV STAT3,8

MAY ALSO CONSIDERone of the following STAT

Inactivated 4F-PCC IV STAT

Weight and INR BASED DOSING3

(using actual body weight, max weight 100 kg, max dose 5000 units)□ INR >1.4 – 4: 25 units/kg□ INR 4.1 – 6: 35 units/kg□ INR >6: 50 units/kg

OR

FIXED DOSING3

□ 1000 units□ 1500 units□ 2000 units

4. If inactivated 4F-PCC given, REPEAT INR within 15-30 minutes after administration

5. If inactivated 4F-PCC used, may give repeat inactivated PCC X1 PRN for refractory bleeding


2. Stop or hold dose(s) if clinically warranted

3. Supportive measures if needed

4. If INR elevated and bleed DOES require hospitalization, intervention and/or transfusion, consider reversal

Vitamin K 1-5 mg IV or PO3,8

Vitamin K:- Vitamin K 1-2 mg provides same INR reduction as higher doses

- Higher doses result in longer duration of reversal

- IV route provides more rapid reversal than PO

- IV formulation of vitamin K may be given orally & provides more dosing flexibility

PCC:Some hospitals may opt to use ACTIVATED PCC. We have provided dosing information for inactivated PCC only, based on available evidence and FDA labeling

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Oral Anticoagulants Critical Major Non-major CommentsDabigatran(Pradaxa®)

Half-life: 12 to 17 hours Prolonged in renal

impairment

Elimination: Renal (80%)

Lab(s) to guide therapy:Thrombin time (TT) More sensitive to presence

of drug A normal TT probably

excludes clinically relevant dabigatran levels, but a prolonged TT does not discriminate between clinically important and insignificant drug concentrations

aPTT If prolonged, suggests

presence of drug Normal aPTT may not

exclude presence of clinically relevant drug levels

Drug class: Direct thrombin inhibitor

1. Hold dabigatran


3. Reversal

Idarucizumab (Praxbind®)5 grams IV STAT2,3,5,9

May repeat 5 grams IV x1 PRN for refractory bleeding

OR

If idarucizumab unavailable:

PCC (activated or inactivated)50 units/kg IV STAT2,3

(Optimal dosing of PCC for dabigatran reversal has not been established and may range from 8-50 units/kg10)

4. May consider activated charcoal (50g) if known recent ingestion within 2-4 hours3

1. Hold dabigatran


3. Reversal

Pursue reversal only if bleeding is not controlled with maximal supportive measures.

Selection and dosing of reversal agents is same as for critical bleeding

1. Hold dabigatran


Dialysis may be considered in patients with continued clinically significant bleeding after reversal administration.

In patients with severe renal dysfunction, laboratory evaluation to detect residual anticoagulant activity is recommended following administration of a reversal agent and consideration of redosing if bleeding persists or recurs

The risks and benefits of repeat idarucizumab administration are not known.

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Oral Anticoagulants Critical Major Non-major CommentsApixaban(Eliquis®)

Half-life:~12 hours

Elimination:Renal (27%)Hepatobiliary/Direct intestinal

Lab(s) to guide therapy:Apixaban-specific anti-Xa assay or LC-MS/MS* may be used to measure apixaban levels.

UFH or LMWH anti-Xa assay is not suitable for measuring apixaban levels. However, a result below the lower limit of quantitation probably excludes clinically relevant apixaban levels.

PT and APTT are not useful for apixaban monitoring. A normal PT and/or APTT does not exclude the presence of clinically relevant apixaban levels.

Drug class:Factor Xa inhibitor

1. Hold apixaban


3. Reversal

□ Andexanet alfa (ANDEXXA®) IV STAT2,3,5

(see andexanet alfa dosing table below)

OR

FIXED DOSE inactivated 4F-PCC 2000 units IV STAT2

OR

WEIGHT-BASED DOSING Inactivated 4F-PCC50 units/kg IV STAT3

(Other 4F-PCC doses, such as 25 units/kg, have been tested and may be appropriate based on the literature; optimal dose has not been defined)

4. May consider activated charcoal (50g) if known recent ingestion within 2-4 hours3

1. Hold apixaban


3. Reversal


Selection and dosing of reversal agents is same as for critical bleeding

1. Hold apixaban


Andexanet alfa is FDA-approved for apixaban reversal

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Oral Anticoagulants Critical Major Non-major CommentsBetrixaban(Bevyxxa®)

Half-life:19-27 hrs


Lab(s) to guide therapy:Betrixaban-specific anti-Xa assay or LC-MS/MS* may be used to measure betrixaban levels.

UFH or LMWH anti-Xa assay is not suitable for measuring betrixaban levels. However, a result below the lower limit of quantitation probably excludes clinically relevant betrixaban levels.

A prolonged PT suggests the presence of clinically relevant betrixaban levels. However, a normal PT does not exclude the presence of clinically relevant betrixaban levels.


1. Hold betrixaban


3. Reversal**

Andexanet alfa IV STAT(see andexanet alfa dosing table below)2,3,5

OR


OR



4. May consider activated charcoal (50g) if known recent ingestion within 2-4 hours

1. Hold betrixaban


3. Reversal**


Selection and dosing of reversal agents is same as for critical bleeding.

1. Hold betrixaban


** There are no approved reversal agents for betrixaban. Evidence supporting reversal is limited. Recommend consulting available clinicians with expertise in reversal if indicated

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Oral Anticoagulants Critical Major Non-major CommentsEdoxaban(Savaysa®)

Half-life:10-14 hrs


Lab(s) to guide therapy:Edoxaban-specific anti-Xa assay or LC-MS/MS* may be used to measure edoxaban levels.

UFH or LMWH anti-Xa assay is not suitable for measuring edoxaban levels. However, a result below the lower limit of quantitation probably excludes clinically relevant edoxaban levels.

A prolonged PT suggests the presence of clinically relevant edoxaban levels. However, a normal PT does not exclude the presence of clinically relevant edoxaban levels.


1. Hold edoxaban


3. Reversal**


OR


OR



4. May consider activated charcoal (50g) if known recent ingestion within 2-4 hours

1. Hold edoxaban


3. Reversal**



1. Hold edoxaban


** There are no approved reversal agents for edoxaban. Evidence supporting reversal is limited. Recommend consulting available clinicians with expertise in reversal if indicated

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Oral Anticoagulants Critical Major Non-major CommentsRivaroxaban(Xarelto®)

Half-life: 5-9 hrs (healthy subjects age 20-45 yrs)11-13 hrs (elderly subjects age 60-76 yrs)


Lab(s) to guide therapy:Rivaroxaban-specific anti-Xa assay or LC-MS/MS* may be used to measure rivaroxaban levels.

UFH or LMWH anti-Xa assay is not suitable for measuring rivaroxaban levels. However, a result below the lower limit of quantitation probably excludes clinically relevant rivaroxaban levels.

A prolonged PT suggests the presence of clinically relevant rivaroxaban levels. However, a normal PT does not exclude the presence of clinically relevant rivaroxaban levels.


1. Hold rivaroxaban


3. Reversal


OR


OR



4. May consider activated charcoal (50g) if known recent ingestion within2-4 hours

1. Hold rivaroxaban


3. Reversal



1. Hold rivaroxaban


Andexanet alfa is FDA-approved for apixaban reversal

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IV/Injectable Anticoagulants11 Critical Major Non-major Comments

Argatroban(Acova®)Half-life: 39 to 51 minutes Hepatic Impairment: 181

minutesElimination: HepaticLab(s) to guide therapy: aPTT/plasma diluted

thrombin timeDrug class: Direct thrombin inhibitor

1. Hold argatroban


3. No established reversal agents**

4. Dialysis may be considered

1. Hold argatroban




1. Stop or hold infusion if clinically warranted


** There are no established reversal agents for argatroban. Evidence supporting reversal is limited. Recommend consulting available clinicians with expertise in reversal if indicated

Short half-life of argatroban may preclude need for reversal strategies

Bivalirudin(Angiomax®)Half-life: Normal renal function and

mild renal impairment: 25 minutes

Moderate renal impairment: 34 minutes

Severe renal impairment: 57 minutes

Dialysis: 3.5 hours

Elimination: Primarily Enzymatic. Urine

(20%), glomerular filtration, tubular secretion, and tubular reabsorption

Lab(s) to guide therapy: aPTT/ plasma dilute

thrombin timeDrug class:Direct thrombin inhibitor

1. Hold bivalirudin




1. Hold bivalirudin






** There are no established reversal agents for bivalirudin. Evidence supporting reversal is limited. Recommend consulting available clinicians with expertise in reversal if indicated

Short half-life of bivalirudin may preclude need for reversal strategies

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Fondaparinux(Arixtra®)

Half-life:17-21 hrs

Elimination:Renal

Lab(s) to guide therapy:Fondaparinux-specific anti-Xa assay may be used to measure fondaparinux levels.

PT and aPTT are not useful for fondaparinux monitoring. A normal PT and/or aPTT does not exclude the presence of clinically relevant fondaparinux levels.


1. Hold fondaparinux


3. Reversal**

Andexanet alfa IV STAT-Insufficient evidence to support a specific dose.-May consider similar andexanet dosing as for oral FXa inhibitors-See andexanet alfa dosing table below

OR

PCC (activated or inactivated)-Insufficient evidence to support a specific dose- May consider similar PCC dosing as for other anticoagulants (e.g., up to 50 units/kg)

OR

Recombinant Factor VIIa(Insufficient evidence to support a specific dose)



3. Reversal**





** There are no established reversal agents for fondaparinux. Evidence supporting reversal is extremely limited. Recommend consulting available clinicians with expertise in reversal if indicated

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Unfractionated Heparin (UFH)

Half-life:~ 60 minutes

Elimination:Reticuloendothelial

Labs to guide therapy:aPTTanti-Xa assay

Drug class:Unfractionated Heparin

1. Hold UFH


3. Reversal

Protamine Sulfate

FIXED DOSE50 mg IV over 10 minutes(May repeat x1 for refractory bleeding)12

OR

CALCULATED DOSE1 mg per 100 units of heparin if < 60 min since last heparin

0.5 mg per 100 units of heparin if 61-120 minutes since last heparin

0.25 mg per 100 units of heparin if 121-180 minutes since last heparin

1. Hold UFH


3. Reversal


Dosing of protamine is same as for critical bleeding.



Protamine will fully reverse UFH

1 mg of protamine will neutralize 100 units of UFH

Maximum dose 50 mg per infusion/push

Give slowly, no faster than 5mg/minute to avoid hypotension

Protamine is derived from fish sperm, and cautious use in patients with fish allergy is imperative

Also, caution with protamine use is required in patients with exposure to NPH or protamine-containing insulin, or history of vasectomy

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Dalteparin(Fragmin®)

Half-life: 5-7 hours (in normal renal function)

Elimination: renal

Lab(s) to guide therapy:anti-Xa assay

Drug class: Low molecular weight heparin (LMWH)

1. Hold dalteparin


3. Reversal1. Protamine Sulfate


OR

CALCULATED DOSE

Time from last LMWH administration: < 8 hours: 1 mg per 100 units

with maximum 50 mg per administration

> 8 hours: 0.5 mg per 100 units with maximum 50 mg per administration

Repeat dose if needed: 0.5 mg per 100 units with

maximum 50 mg per administration

1. Hold dalteparin


3. Reversal

Pursue reversal only if bleeding is not controlled with maximal supportive measures

Dosing of protamine is same as for critical bleeding



Protamine will only reverse approximately 60% of LMWH anti-Xa activity





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Enoxaparin(Lovenox®)

Half-life: 5-7 hours (in normal renal function)

Elimination: renal

Lab(s) to guide therapy: anti-Xa assay

Drug class: Low molecular weight heparin (LMWH)

1. Hold enoxaparin


3. ReversalProtamine Sulfate


OR

CALCULATED DOSE

Time from last LMWH administration:

< 8 hours: 1 mg per 100 units with maximum 50 mg per administration

> 8 hours: 0.5 mg per 100 units with maximum 50 mg per administration

Repeat dose if needed: 0.5 mg per 100 units with

maximum 50 mg per administration

1. Hold enoxaparin


3. Reversal

Pursue reversal only if bleeding is not controlled with maximal supportive measures

Dosing of protamine is same as for critical bleeding



Protamine will only reverse approximately 60% of LMWH anti-Xa activity





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Resumption of Anticoagulation2,3,5,13 Critical Major Non-major Comments

After extracranial bleed (e.g., gastrointestinal):

Balance risk of thromboembolism and bleeding and resume when able

After intracranial bleed: If traumatic, balance risk of

thromboembolism and bleeding and resume when able

If spontaneous LOBAR consider alternatives to anticoagulation

If spontaneous NON-LOBAR, consider re-initiation of anticoagulation in 1 month

Same as critical Same as critical Lobar hemorrhage= occurring in the frontal, parietal, temporal or occipital cerebral lobe

* LC-MS/MS= Liquid chromatography/tandem mass spectrometry

Table: Andexanet alfa dosing Factor Xa inhibitor Last dose Timing of last dose

< 8 hours or unknown ≥ 8 hoursApixaban ≤ 5 mg Low-dose1 Low-dose1

> 5 mg or unknown High-dose2 Low-dose1

Betrixaban3 Any High-dose2 High-dose2

Edoxaban3 Any High-dose2 High-dose2

Rivaroxaban ≤ 10 mg Low-dose1 Low-dose1

> 10 mg or unknown High-dose2 Low-dose1

1Initial 400 mg IV bolus at target rate of 30 mg/min followed by continuous infusion at 4 mg/min for up to 120 min2Initial 800 mg IV bolus at target rate of 30 mg/min followed by continuous infusion at 8 mg/min for up to 120 min3Andexanet alfa is not FDA-approved for reversal of betrixaban or edoxaban and dosing of andexanet alfa for reversal of these agents has not been established

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References:1. https://www.jointcommission.org/assets/1/18/R3_19_Anticoagulant_therapy_FINAL2.PDF Accessed 12/11/192. Cuker A, et al. Reversal of direct oral anticoagulants: Guidance from the Anticoagulation Forum. Am J Hematol. 2019 Jun;94(6):697-7093. Tomaselli GF, et al. 2017 ACC Expert Consensus Decision Pathway on Management of Bleeding in Patients on Oral Anticoagulants: A

Report of the American College of Cardiology Task Force on Expert Consensus Decision Pathways. J Am Coll Cardiol 2017;70:3042–674. Horlocker T, et al. Regional Anesthesia in the Patient Receiving Antithrombotic or Thrombolytic Therapy: American Society of Regional

Anesthesia and Pain Medicine Evidence-Based Guidelines (Fourth Edition). Regional Anesthesia and Pain Medicine 2018; 43 93): 263–309. doi: 10.1097/AAP.0000000000000763

5. Witt DM, et al. .American Society of Hematology 2018 guidelines for management of venous thromboembolism: optimal management of anticoagulation therapy. Blood Adv. 2018 Nov 27; 2(22): 3257–3291. doi: 10.1182/bloodadvances.2018024893

6. Schulman S, et al. Definition of major bleeding in clinical investigations of antihemostatic medicinal products in non-surgical patients: on behalf of the subcommittee on control of anticoagulation of the scientific and standardization committee of the International Society on Thrombosis and Haemostasis. J Thromb Haemost2005;3: 692–4

7. Kaatz S, et al. Definition of clinically relevant non-major bleeding in studies of anticoagulants in atrial fibrillation and venous thromboembolic disease in non-surgical patients: communication from the SSC of the ISTH. J Thromb Haemost2015;13: 2119–26

8. Holbrook A, et al. Evidence-Based Management of Anticoagulant Therapy Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. CHEST 2012; 141(2)(Suppl):e152S–e184S

9. Frontera, JA. Guideline for Reversal of Antithrombotics in Intracranial Hemorrhage A Statement for Healthcare Professionals from the Neurocritical Care Society and Society of Critical Care Medicine. Neurocrit Care (2016) 24:6–46 DOI 10.1007/s12028-015-0222-x

10. Dager WE, et al. Effect of low and moderate dose FEIBA to reverse major bleeding in patients on direct oral anticoagulants. Thrombosis Research 173 (2019) 71–76

11. Garcia DA, et al. Parenteral anticoagulants: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012 Feb;141(2 Suppl):e24S-e43S. doi: 10.1378/chest.11-2291

12. Heparin. In: Lexi-drugs online. Hudson, Ohio: Wolters Kluwer Clinical Drug Information, Inc.; Last updated 12/13/19. Available at http://online.lexi.com/lco/action/search?q=heparin&t=name&va=heparin Accessed 12/11/19. Subscription required to view

13. Hemphill JC III, et al. Guidelines for the Management of Spontaneous Intracerebral Hemorrhage: A Guideline for Healthcare Professionals from the American Heart Association/American Stroke Association. Stroke. 2015 Jul;46(7):2032-60. doi: 10.1161/STR.0000000000000069

About the Anticoagulation Forum The Anticoagulation Forum is the largest organization of anticoagulation management specialists in North America. The organization’s mission is to improve the quality of care for patients taking antithrombotic medications by educating healthcare professionals and advocating for clinical best practices. www.acforum.org

Contributors: This document was created by members of the Anticoagulation Forum Board of Directors, including: Geoffrey Barnes, MD, MS; Allison Burnett, PharmD, PhC, CACP; Adam Cuker, MD, MS; William E. Dager, PharmD, BCPS, MCCM, FCSHP, FACCP, FASHP; Steven Deitelzweig, MD, MMM, FACC, SFHM, FACP, RVT; Scott Kaatz, DO, MSc, FACP, SFHM

This project is funded in part by an educational grant from Portola Pharmaceuticals, Inc.Version 1, 12/19/19 18

http://www.acforum.org/

https://www-ncbi-nlm-nih-gov.libproxy.unm.edu/pubmed/26022637

http://online.lexi.com/lco/action/search?q=heparin&t=name&va=heparin

https://www.ncbi.nlm.nih.gov/pubmed/30916798

https://www.jointcommission.org/assets/1/18/R3_19_Anticoagulant_therapy_FINAL2.PDF

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