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Am J Med. 2016 Nov;129(11S):S54-S63. doi: 10.1016/j.amjmed.2016.06.006. Epub 2016 Aug 26.

Re-Initiation of Dabigatran and Direct Factor Xa Antagonists After a Major Bleed.

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Departments of Neurology and Surgery and Perioperative Care, Seton Dell Medical School Stroke Institute, Austin, TX. Electronic address:
Department of Medicine, Anticoagulation and Clinical Thrombosis Services, Hofstra North Shore-LIJ School of Medicine, North Shore-LIJ Health System, Manhasset, NY.


Direct oral anticoagulants (DOACs) are a relatively recent addition to the oral anticoagulant armamentarium, and provide an alternative to the use of vitamin K antagonists such as warfarin. Regardless of the type of agent used, bleeding is the major complication of anticoagulant therapy. The decision to restart oral anticoagulation following a major hemorrhage in a previously anticoagulated patient is supported largely by retrospective studies rather than randomized clinical trials (mostly with vitamin K antagonists), and remains an issue of individualized clinical assessment: the patient's risk of thromboembolism must be balanced with the risk of recurrent major bleeding. This review provides guidance for clinicians regarding if and when a patient should be re-initiated on DOAC therapy following a major hemorrhage, based on the existing evidence.


Direct-acting oral anticoagulants; Gastrointestinal bleeding; Intracranial hemorrhage; Major hemorrhage; Restart oral anticoagulants; Warfarin

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