Join/Renew

ACEP ID:

Direct Oral Anticoagulants

Scope of Application

This guideline is intended for physicians working in emergency departments.

Inclusion Criteria

This guideline is intended for patients aged ≥16 years who present to the ED on a direct oral anticoagulant with acute major symptomatic bleeding.

Exclusion Criteria

This guideline is not intended for pediatric patients.

Recommendations offered in this policy are not intended to represent the only diagnostic and management options that the emergency physician should consider. ACEP recognizes the importance of the individual physician’s judgment and patient preferences.

Critical Questions

  • In adult ED or ICU patients on DOACs with acute major symptomatic bleeding, does using an agent-specific antidote compared with usual care (eg, PCC) improve clinical outcomes?

    Recommendations
    Level A Recommendations

    None specified.

    Level B Recommendations

    None specified.

    Level C Recommendations

    In adult ED patients on dabigatran with acute major symptomatic bleeding, idarucizumab may be considered and should be weighed against potential risk of thrombotic events.

    In adult ED patients on factor Xa inhibitors with acute major symptomatic bleeding, usual care including four-factor PCC may be considered. Outside the United States where andexanet alfa remains available, its use may be considered after weighing uncertain outcome-centered benefit, thrombotic risk, and cost (Consensus recommendation).

    Shared decision making with patients or surrogate decision makers may be helpful to frame potential benefits and risks of any acute anticoagulation reversal (Consensus recommendation).

    Level A Recommendations

    None specified.

    Level B Recommendations

    None specified.

    Level C Recommendations

    In adult ED patients on dabigatran with acute major symptomatic bleeding, idarucizumab may be considered and should be weighed against potential risk of thrombotic events.

    In adult ED patients on factor Xa inhibitors with acute major symptomatic bleeding, usual care including four-factor PCC may be considered. Outside the United States where andexanet alfa remains available, its use may be considered after weighing uncertain outcome-centered benefit, thrombotic risk, and cost (Consensus recommendation).

    Shared decision making with patients or surrogate decision makers may be helpful to frame potential benefits and risks of any acute anticoagulation reversal (Consensus recommendation).

Download the Policy

PDF Icon Direct Oral Anticoagulant-cp.pdf June 2026

Findings and Strength of Recommendations

Clinical findings and strength of recommendations regarding patient management were made according to the following criteria:
Level A recommendations
Generally accepted principles for patient care that reflect a high degree of clinical certainty (eg, based on evidence from 1 or more Class of Evidence I or multiple Class of Evidence II studies).
Level B recommendations
Recommendations for patient care that may identify a particular strategy or range of strategies that reflect moderate clinical certainty (eg, based on evidence from 1 or more Class of Evidence II studies or strong consensus of Class of Evidence III studies).
Level C recommendations
Recommendations for patient care that are based on evidence from Class of Evidence III studies or, in the absence of adequate published literature, based on expert consensus. In instances in which consensus recommendations are made, “consensus” is placed in parentheses at the end of the recommendation.
There are certain circumstances in which the recommendations stemming from a body of evidence should not be rated as highly as the individual studies on which they are based. Factors such as heterogeneity of results, uncertainty about effect magnitude, and publication bias, among others, might lead to a downgrading of recommendations.
[ Feedback → ]