WSC 2025 | Guidance on the reversal of anticoagulation in patients with ICH related to oral anticoagulants

So in patients with an ICH which might be associated with the treatment with an oral anticoagulant, there are three scenarios. Scenario number one, the patient is on a vitamin K antagonist. In this case, patients should be treated with prothrombin complex and added by therapy with vitamin K replacement, 10 milligrams IV, actually at the same time when PCC is administered. The second situation is patients who have an ICH while they are on a thrombin inhibitor like dabigatran. In this case, ESO recommends to use or to consider the use of idarucizumab. The third situation is patients who have an ICH associated with a factor Xa inhibitor. In these cases, we recommend to consider the use of andexanet alfa if the bleeding is related to rivaroxaban or apixaban. All these are actually not a recommendation according to the so-called GRADE system, which is the system we are using in the guideline, but they are expert consensus statements. And the reason is because all the evidence comes from either indirect evidence, small randomized controlled trials or the endpoints of a randomized controlled trial like for andexanet is not or was not an outcome as we had defined it to be an outcome in the guideline.

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