Renal impairment (CrCl Extremes of body weight (£ 50 kg or ³ 120 kg).Significant drug interactions – see general principles.Indwelling spinal or epidural catheter and during the first 6 hours after removal.Organ lesions at risk of bleeding including ICH in previous 6 months.Significant active bleeding or bleeding disorder.Moderate-to-severe renal failure (CrCl Significant valvular heart disease or mechanical heart valve.Prevention of VTE after elective hip or knee replacement (not in ED).Atrial fibrillation with one or more additional risk factors for stroke (possibly in ED).Treatment of acute DVT or PE, and secondary prevention of same (often in ED).NOAC Guidelines: Registered indications (CEC, July 2017). (Fox et al., 2012 and EINSTEIN Investigators, 2010) Possible increase in incidence of GI bleeding.Not suitable for prosthetic heart valves or in those with moderate-to-severe renal failure.Less experience with reversal of dabigatran at the time of writing, no specific reversal agent for rivaroxaban and apixaban available.Possibly lower incidence of life-threatening bleeding.Less likely to interact with foods, other drugs or illnesses.Onset of action within 2-3 hours (apixaban and rivaroxaban does not require bridging with heparin or LMWH).Fixed doses and no need for frequent blood tests as pharmacokinetics are more predictable however renal function should be monitored particularly in those with chronic kidney disease or those who are elderly.NOAC Guidelines: Commencing treatment (CEC, July 2017).Ĭonsider the advantages and disadvantages of starting treatment with a NOAC as opposed to LMWH and warfarin.Rivaroxaban and apixaban are highly protein-bound and hence NOT dialysable. It has been shown to normalise prothrombin time in a trial of 12 healthy male subjects at a dose of 50 IU/kg (administered as a slow IV injection) (Eerenberg et al., 2011). For life-threatening bleeding or emergency surgery, consider the use of prothrombin complex concentrate (Prothrombinex®-VF) in consultation with haematology (risk of thrombotic complications).Idarucizumab: Reversing the effects of Dabigatran (CEC Factsheet, August 2016).aPTT >80 seconds or a dabigatran level >500 mg/mL.
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