What is the management for a bleeding skin wound that won't stop in a patient on anticoagulants (anti-coagulant medications)?

From the Guidelines

In patients on anticoagulants, such as warfarin, aspirin, or novel oral anticoagulants (NOACs) like apixaban or rivaroxaban, who present with a skin wound that won't stop bleeding, immediate action is required.

Initial Management

The patient should apply firm and sustained pressure to the wound for at least 10-15 minutes.

• If bleeding persists, consider administering 1-2 grams of tranexamic acid orally or intravenously.

Anticoagulant Reversal

Additionally, the patient's anticoagulant medication may need to be temporarily withheld or reversed, such as with:

• Vitamin K (10 mg intravenously) for warfarin 1
• Andexanet alfa (400-800 mg intravenously) for factor Xa inhibitors like apixaban or rivaroxaban 1

Reversal Agents

For warfarin, prothrombin complex concentrate (PCC) is the preferred reversal agent, administered intravenously in a dose of 25–50 U/kg 1.

• Four-factor PCC is preferred over 3-factor PCC due to its more successful INR reversal and lower adverse events 1.

Considerations

The decision to restart anticoagulation after a bleeding event should be made on a case-by-case basis, considering the patient's individual risk of thromboembolism and bleeding 1.

• In general, anticoagulation should be restarted as soon as possible after the bleeding has been controlled, unless there is a high risk of rebleeding or other contraindications 1.

From the FDA Drug Label

When heparin and warfarin sodium tablets are administered concomitantly... Whole blood or component therapy may also be necessary if bleeding is severe. The management for a bleeding skin wound that won't stop in a patient on anticoagulants may involve discontinuation of anticoagulant therapy and whole blood or component therapy if bleeding is severe 2 3.

• Stop the anticoagulant: Discontinue warfarin sodium tablets if suspected to be the cause of bleeding.
• Whole blood or component therapy: May be necessary if bleeding is severe.
• Monitor prothrombin time (PT)/International Normalized Ratio (INR): To control anticoagulant therapy. Note: No specific treatment for bleeding skin wound is uniformly effective, and treatment should be individualized.

From the Research

Management of Bleeding Skin Wounds in Patients on Anticoagulants

The management of bleeding skin wounds in patients on anticoagulants involves achieving rapid and controlled haemostasis to save the patient's life 4. The approach to management depends on the type of anticoagulant the patient is taking.

Reversal of Anticoagulation

For patients on vitamin K antagonists, such as warfarin, the administration of vitamin K and repletion of clotting factors with four-factor prothrombin complex concentrate can help stop the bleeding 4, 5. For patients using a direct oral anticoagulant, specific antidotes are necessary to reverse the anticoagulative effect. For example, idarucizumab is used to reverse the effects of dabigatran, a thrombin inhibitor 4, 5, while andexanet alfa is used to reverse the effects of factor Xa inhibitors, such as apixaban and rivaroxaban 4, 5.

Treatment Strategies

Specific treatment strategies are discussed in patients using anticoagulants with major traumatic bleeding, intracranial haemorrhage, or gastrointestinal bleeding 4. The choice of treatment strategy depends on the severity of the bleeding and the type of anticoagulant the patient is taking.

Key Considerations

• The management of bleeding skin wounds in patients on anticoagulants requires a systematic and pragmatic approach 4.
• The type of anticoagulant the patient is taking determines the approach to management 4, 5.
• Specific antidotes are necessary to reverse the anticoagulative effect of direct oral anticoagulants 4, 5.
• Treatment strategies depend on the severity of the bleeding and the type of anticoagulant the patient is taking 4.

Advantages and Disadvantages of New Oral Anticoagulants

New oral anticoagulants, such as dabigatran, rivaroxaban, and apixaban, have several advantages over traditional vitamin K antagonists, including a lower incidence of major bleeding, convenience of use, and minimal drug and food interactions 6. However, there are also some disadvantages, such as the need for specific antidotes to reverse their effects in the event of bleeding 4, 5.

Drug and Dietary Interactions

Clinicians need to be vigilant when initiating any of these agents or when any changes in the patient's medication profile occur, and perform a close screening for potential drug and dietary interactions 7. The list of drugs and supplements that interact with warfarin is continuously expanding, and the knowledge on drug interactions with the novel oral anticoagulants is still in its infancy 7.

Prevention of Stroke and Systemic Embolic Events

Novel oral anticoagulants have been shown to significantly reduce stroke or systemic embolic events by 19% as compared with warfarin, mainly driven by a reduction in hemorrhagic stroke, while their administration also significantly reduced all-cause mortality by 10% and intracranial hemorrhage by 52% 8.