European Stroke Organisation (ESO) Guideline on Reversal of Oral Anticoagulants in Acute Intracerebral Haemorrhage

Published by ESO on May 14, 2021

Disclaimer


The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Christensen: Travel support and speaker honoraria from Boehringer Ingelheim, Bayer and Merck Sharp & Dohme (MSD); Cordonnier: Speaker honoraria from Pfizer and Boehringer Ingelheim; Korv: Travel support and speaker honoraria from Pfizer, Boehringer Ingelheim and Bayer; Lal: None; Ovesen: Travel support from Merck Sharp & Dohme (MSD); Purrucker: Travel support and speaker honoraria from Pfizer, Boehringer Ingelheim; Toni: Speaker honoraria and advisory board on direct anticoagulants for Boehringer Ingelheim, Bayer, Pfizer Merck Sharp & Dome, Daiichi Sankyo; Steiner: Speaker and consultation fees from Bayer, BMS Pfizer, Boehringer-Ingelheim, Daiichi Sankyo, Research grant from Octapharma; Steiner abstained from the voting process on PICO 2 and 8 due to perceived intellectual conflicts of interests.

Sponsors

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the European Stroke Organisation through funding the salary of the methodologist (AL).

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Abstract

The aim of the present European Stroke Organisation guideline document is to provide clinically useful evidence-based recommendation on reversal of anticoagulant activity VKA (warfarin, phenprocoumon and acenocoumarol), direct factor II (thrombin) inhibitors (dabigatran etexilat) and factor-Xa-inhibitors (apixaban, edoxaban and rivaroxaban) in patients with acute intracerebral haemorrhage. The guideline was prepared following the Standard Operational Procedure for a European Stroke Organisation guideline document and according to GRADE methodology. As a basic principle, we defined use of oral anticoagulation pragmatically: oral anticoagulation use is assumed by positive medical history unless relevant anticoagulant activity is regarded unlikely by medical history or has been ruled out by laboratory testing. Overall, we strongly recommend using prothrombin complex over no treatment and fresh-frozen plasma in patients on VKA plus vitamin K.We further strongly recommend using idarucizumab in patients on dabigatran and make a recommendation for andexanet alfa in patients on rivaroxaban and apixaban over no treatment. We make a weak recommendation on using high-dose prothrombin complex concentrate (50 IU/kg) for all patients taking edoxaban and for patients on rivaroxaban or apixaban in case andexanet alfa is not available. We recommend against using tranexamic acid and rFVIIa, outside of trials. The presented treatment recommendations aim to normalise coagulation, there is no or only indirect data on effects on functional outcome or mortality, and only little data from randomised controlled trials.

Language

en

PICOS

PICO 1.1

Population
Adults with ICH occurring during use of vitamin K antagonists (with an international normalised ratio (INR) above normal)
Intervention
PCC
Comparator
Placebo
Outcomes

PICO 2.1

Population
Adult patients with ICH occurring during use of VKA
Intervention
PCC
Comparator
FFP
Outcomes

PICO 4.1

Population
Adult patients with ICH occurring during use of VKA
Intervention
FFP
Comparator
Vitamin K
Outcomes

PICO 4.2

Population
Adult patients with ICH occurring during use of VKA
Intervention
PCC
Comparator
Vitamin K
Outcomes

PICO 5.1

Population
Adults with ICH occurring during use of VKA
Intervention
rFVII
Comparator
FFP and vitamin K
Outcomes

PICO 7.1

Population
Adult patients with ICH occurring during use of VKA (with an INR above normal)
Intervention
PCC
Comparator
Placebo
Outcomes

PICO 8.1

Population
Adult patients with ICH occurring during use of dabigatran etexilate
Intervention
Idarucizumab
Comparator
No treatment
Outcomes

PICO 9.1

Population
Adult patients with ICH occurring during use of a fXa inhibitor
Intervention
Andexanet
Comparator
No treatment
Outcomes