Direct oral anticoagulants and the management of bleeding

Over the past decade direct oral anticoagulants (DOACs) have become an increasingly popular choice in the treatment and prevention of venous and arterial thromboembolism, owing to the convenience of fixed dosing. Large Phase III studies and meta-analyses have shown that the risk of intracranial and fatal bleeding with DOACs is lower than with anticoagulation using vitamin K antagonists. Despite this, there was initially some hesitancy among clinicians and patients in using these anticoagulants owing to the lack of reversal agents, and the challenges in accurately measuring their anticoagulant effect, in situations of major bleeding. The need for effective reversal agents was quickly recognized after the development of DOACs, and two DOAC-specific reversal agents have been licensed. The emergence of agents that can rapidly reverse their anticoagulant effects, along with increasing experience in the management of DOAC-related bleeding, has led to clinician and patient confidence in these anticoagulants.