DOAC- Associated Bleeding

Risks and Reversal Strategies

Educational Objectives

After participating in this activity, pharmacists will be able to:

  • Describe the burden of illness from anticoagulant-associated severe bleeding
  • Identify high-risk factors in DOAC-associated bleeding, including intracranial hemorrhage, GI bleeding and critical area or organ
  • Describe reversal treatments for DOAC-associated bleeds
  • Apply guidelines for reversing DOACs
  • Discuss patient evaluation and institutional protocol concepts for DOAC reversal

After participating in this activity pharmacists and pharmacy technicians will be able to:

  • Discover resources for patient information on anticoagulation and bleeding risk
  • Identify the medications used in DOAC anticoagulation therapy
  • Recall the medications used to reverse DOAC anticoagulation therapy
  • Determine when to refer the patient to the pharmacist regarding DOAC anticoagulation therapy

Session Offered

Release Date: June 15, 2019

Expiration Date: December 15, 2021

Course Fee


Session Codes

19YC45-FCT83 Pharmacist

19YC45-KBT92 Pharmacy Technician

Accreditation Hours

2.0 hours of CE


The use of direct oral anticoagulants (DOACs) for the treatment and prevention of thromboembolic events has steadily increased. The DOACs offer an improved risk/benefit profile with regard to their comparable efficacy and decreased risk of bleeding compared to vitamin K antagonists. Despite their association with decreased risks of major bleeding, DOACs, as with all anticoagulant medications, put patients at risk of bleeding. Until recently, one advantage vitamin K antagonists possessed over DOACs was a drug-specific antidote to reverse their anticoagulant effects. The development of idarucizumab for dabigatran and andexanet alfa for rivaroxaban and apixaban has partially addressed this need. However, there is still no FDA-approved reversal agent for edoxaban or betrixaban. Furthermore, clinicians must consider key differences at the individual patient level regarding bleeding risk and management. The American College of Cardiology recently published a consensus decision pathway to help guide the management of oral anticoagulant-associated bleeding. This pathway is a useful tool in the management of DOACs, but the topic of DOAC-associated bleeding is a rapidly evolving topic, with new data becoming available, and further reversal agents in the pipeline.

Accreditation Statements

The University of Connecticut School of Pharmacy is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education.

Pharmacists and pharmacy technicians are eligible to participate in this application-based activity and will receive up to 0.2 CEU (2 contact hours) for completing the activity, passing the quiz with a grade of 70% or better, and completing an online evaluation. Statements of credit are available via the CPE Monitor on- line system and your participation will be recorded with CPE Monitor within 72 hours of submission


Grant funding: Portola Pharmaceuticals

Cost: Free

Initial Release Date: June 15, 2019
Expiration Date: December 15, 2021

To obtain CPE credit, visit the UConn Online CE Center

Use your NABP E-profile ID and the session code 19YC45-FCT83 for pharmacists or 19YC45-KBT92for pharmacy technicians to access the online quiz and evaluation.

First- time users must pre-register in the Online CE Center. Test results will be displayed immediately and your participation will be recorded with CPE Monitor within 72 hours of completing the requirements.

For questions concerning the online CPE activities, email


Brandon K. Martinez, PharmD, BCPS ; Cardiovascular Outcomes Research Fellow, Hartford Hospital Evidence Based Practice Center, Hartford, CT, University of Connecticut School of Pharmacy, Storrs, CT .

Faculty Disclosure

The author has no actual or potential conflicts of interest associated with this article.

Disclosure of Discussions of Off-label and Investigational Drug Use

This activity may contain discussion of off label/unapproved use of drugs. The content and views presented in this educational program are those of the faculty and do not necessarily represent those of the University of Connecticut School of Pharmacy. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.



The Centers for Disease Control and Prevention (CDC) +-estimates that more than 900,000 venous thromboembolism (VTE) events, including deep vein thrombosis (DVT) and pulmonary embolism (PE), occur in the United States (US) annually. VTE is associated with high recurrence and mortality rate (60,000-100,000 Americans die from VTE each year).1 Additionally, approximately 2.7 million people in the US have nonvalvular atrial fibrillation (NVAF; see Sidebar, page 2) with the prevalence expected to grow to 12.1 million by 2030.2 Patients with atrial fibrillation are at an increased risk of stroke and systemic thromboembolic events.


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