• A patient who is on anticoagulation therapy is at risk for development of thrombosis after reversal of anticoagulation
• All anticoagulation reversal agents are potentially thrombogenic
• rVIIa corrects INR, but it does not correct warfarin-induced coagulopathy
• Kcentra is a 4-factor prothrombin complex concentrate (PCC) and is the only PCC FDA approved for warfarin reversal. If using 3-factor PCC, consider concomitant FFP as 3-factor PCC contains negligible quantities of FVII
• Administering PCC and rVIIa together significantly increases the risk of thrombosis
• When starting NOAC treatment for DVT, Edoxoban and Dabigatran require an initial 5-10 days of parenteral anticoagulation, whereas Apixaban and Rivaroxaban do not
• NOACs are contraindicated if INR is elevated due to liver disease; INR in this situation may not reflect antithrombotic effect
• Protamine sulfate has anticoagulant properties
• LMWH is the anticoagulant of choice in patients who are pregnant or who have active cancer
• Initiation of anticoagulation after surgical procedure should be based on thrombotic risk vs. risk of bleeding due to the procedure
• There is a lag period between reversal of anticoagulant effect and reconstitution of hemostasis
• Consider consulting with a hematologist before complete reversal

General principles of management of anticoagulant-associated bleeding, as recommended by the American Society of Hematology, are represented by the acronym HASHTI³:

• Hold anticoagulant
• Consider Antidote, if available
• Supportive treatment
  • Volume resuscitation
  • Hemodynamic support
• Hemostasis (Local/Surgical)
  • Consider antifibrinolytic agents (aminocaproic acid, tranexamic acid)
• Transfusion
  • RBCs for severe/symptomatic anemia
  • Platelets for thrombocytopenia <50 x 10⁹/L or patient on long-acting antiplatelet agent
• Investigate for bleeding source