How do you reverse antiplatelet (anti-platelet) agents in cases of severe bleeding?

Reversal of Antiplatelet Agents in Severe Bleeding

For severe bleeding on antiplatelet agents, immediately discontinue the drug and use platelet transfusion only for patients requiring neurosurgical procedures with aspirin or ADP inhibitor exposure, while avoiding platelet transfusion in non-surgical cases due to lack of benefit and potential harm. 1

Immediate Management Steps

Discontinue Antiplatelet Therapy

• Stop all antiplatelet agents immediately when severe bleeding is present or suspected 1
• Irreversible antiplatelet agents (aspirin, clopidogrel, prasugrel) have prolonged duration of action such that temporary discontinuation may not have clinical effect for several days 1
• Ticagrelor is the exception as a reversible platelet inhibitor with half-life of 7-9 hours, allowing more rapid recovery of platelet function 1

Supportive Care First

• Secure airway and establish large-bore intravenous access 1
• Apply local hemostatic measures including direct pressure, packing, and topical hemostatic agents 1
• Aggressive volume resuscitation with isotonic crystalloids (0.9% NaCl or Ringer's lactate) to restore hemodynamic stability 1
• Transfuse RBCs to maintain hemoglobin ≥7 g/dL (≥8 g/dL in patients with coronary artery disease) 1

Platelet Transfusion Strategy

When to AVOID Platelet Transfusion

Platelet transfusion is NOT recommended for the following scenarios:

• Non-surgical intracranial hemorrhage regardless of antiplatelet type, platelet function testing results, hemorrhage volume, or neurologic examination 1
• NSAID-related intracranial hemorrhage, even with planned neurosurgical intervention 1
• Glycoprotein IIb/IIIa inhibitor-related intracranial hemorrhage, even with planned neurosurgical intervention 1
• Patients with laboratory-documented normal platelet function or documented antiplatelet resistance 1

When Platelet Transfusion IS Indicated

Platelet transfusion should be considered for:

• Aspirin- or ADP inhibitor-associated (clopidogrel, prasugrel, ticagrelor) intracranial hemorrhage in patients who WILL undergo neurosurgical procedures 1
• Perform platelet function testing prior to transfusion if available to confirm platelet dysfunction 1
• When platelet testing is not readily available, empiric platelet transfusion may be reasonable in surgical candidates 1

Dosing for Platelet Transfusion

• Initial dose: one single donor apheresis unit of platelets 1
• Perform platelet function testing prior to repeat transfusion if available 1
• Repeat transfusion only for patients with persistently abnormal platelet function tests 1

Adjunctive Pharmacologic Therapy

Desmopressin (DDAVP)

• Consider single dose of desmopressin 0.4 μg/kg IV for aspirin/cyclooxygenase-1 inhibitor or ADP receptor inhibitor-associated intracranial hemorrhage 1
• Can be used in patients deemed appropriate for intervention, particularly those undergoing neurosurgical procedures 1
• NOT recommended for routine use in non-intracranial severe bleeding due to lack of clinical evidence 1

Topical Hemostatic Agents

• Gauze soaked in tranexamic acid can be applied as local hemostatic measure 2
• Direct manual compression with gauze for accessible bleeding sites 2

Critical Pitfalls to Avoid

Platelet Transfusion Risks

• New data suggest platelet transfusion is associated with increased mortality in some bleeding contexts 1
• Avoid routine platelet transfusion in non-surgical bleeding as it has not been shown to improve outcomes 1
• The decision to transfuse platelets should be restricted to surgical candidates with confirmed platelet dysfunction 1

Laboratory Testing Considerations

• Platelet function testing should guide transfusion decisions when available, but should not delay urgent surgical intervention 1
• Do not transfuse platelets if testing confirms normal platelet function or antiplatelet resistance 1

Concomitant Anticoagulation Management

If Patient is on Both Antiplatelet and Anticoagulant

• Prioritize reversal of anticoagulation first, as anticoagulation alone offers minimal protection against stent thrombosis while increasing bleeding risk 1
• Weigh risk versus benefit of stopping antiplatelet agents in major bleeding, considering thrombotic risk 1
• For high thrombotic risk patients (e.g., recent stent placement within 1 month), higher threshold should be considered for complete cessation 1

Timing of Antiplatelet Resumption

• Duration of interruption should be tailored to severity of bleeding and likelihood of controlling the source 1
• For irreversible antiplatelet agents, clinical effect of discontinuation may not manifest for several days, by which time bleeding is typically controlled 1
• Balance thrombotic risk (particularly early post-stent) against bleeding risk when deciding resumption timing 1