Bleeding due to Drugs

For major bleeding due to Thrombolytics (e.g. intracerebral) within 48 h of administration

• IV access, send FBC, U&E, clotting screen
• Take expert Haematology advice/Local protocols
• Stop infusion of fibrinolytic drugs and other antithrombotic drugs
• Administer Fresh Frozen Plasma 12 ml/kg
• Administer IV Tranexamic acid 1 g tds (2C).
• If there is low fibrinogen, administer cryoprecipitate or fibrinogen concentrate
• Further therapy should be guided by results of coagulation tests

Warfarin and High INR

• Major bleeding
  • ABC, IV access, achieve haemostasis and Stop warfarin sodium
  • Give phytomenadione (vitamin K1) by slow intravenous injection
  • Give dried Prothrombin complex (factors II, VII, IX, and X) but if dried prothrombin complex unavailable, FFP can be given but is less effective
  • Recombinant factor VIIa is not recommended for emergency anticoagulation
• Minor Bleeding reversal INR >8.0
  • Stop warfarin sodium
  • Give phytomenadione (vitamin K1) by slow intravenous injection; repeat dose of phytomenadione if INR still too high after 24 hours
  • Restart warfarin sodium when INR <5.0
• INR >8.0, no bleeding
  • Stop warfarin sodium
  • Give phytomenadione (vitamin K1) by mouth using the IV preparation orally [unlicensed use]
  • Repeat dose of phytomenadione if INR still too high after 24 hours; restart warfarin when INR <5.0
• INR 5.0-8.0, minor bleeding
  • Stop warfarin sodium
  • Give phytomenadione (vitamin K1) by slow IV injection
  • Restart warfarin sodium when INR <5.0
• INR 5.0-8.0, no bleeding
  • Withhold 1 or 2 doses of warfarin sodium and reduce subsequent maintenance dose
  • Unexpected bleeding at therapeutic levels - always investigate possibility of underlying cause e.g. unsuspected renal or gastro-intestinal tract pathology

Bleeding due to Rivaroxaban

• There is no specific antidote for rivaroxaban.
• Management of bleeding should be through cessation of treatment and general haemostatic measures
• In situations with ongoing life-threatening bleeding, PCC, APCC and rFVIIa should be considered

References

• BNF Guidance