Effect of low and moderate dose FEIBA to reverse major bleeding in patients on direct oral anticoagulants

Objective: Management of acute, major or life threatening bleeding in the presence of direct acting oral anticoagulants (DOAC) is unclear. In the absence of a specific antidote, or in situations where there is a need for adjunctive therapy, the ideal prothrombin complex concentrate and dose is unclear. The goal of our study was to evaluate the outcomes of our reduced dosing strategy with FEIBA in patients experiencing a DOAC-related bleeding event. Design: Retrospective analysis of patients treated with FEIBA for a DOAC-related bleeding event. Setting: Academic medical center Patients: Consecutive patients between May 2011 and April 2017 receiving FEIBA for a DOAC-related bleed Interventions: None Measurements & main results: Of the 64 patients included in this analysis, 38 patients received low dose FEIBA (mean 10.0 +/- 3.6 units/kg) and 26 received moderate dose (mean 24.3 +/- 2.1 units/kg) FEIBA; an additional dose was requested in 6 patients. Six dabigatran patients received idarucizumab. 30 day event rates included 5 thromboembolic events (8%) and 9 (14%) patients expired. Follow-up CT-imaging for ICH, endoscopy/colonoscopy, or interventional radiology exams did not reveal any clinically concerning active bleeding or hematoma expansion except in 2 ICH patients with slight expansion between imaging sessions. Conclusions: Low (< 20 units/kg) to moderate (20-30 units/kg) doses of FEIBA, with the option for a repeat dose, may be an effective management strategy for obtaining hemostasis in DOAC-related major bleeding events.