Bleeding on anticoagulants - interesting snippet of info

I wanted to share what I heard from my lovely GP yesterday (Moaning Mrytle having been give the heave) .

I asked what would happen in the event of a serious bleed while taking NOAC currently without "antidote".

Firstly he said he had seen recent literature from a drug company that they had developed an antidote for apixiban although it may be a few months before it is adopted by our local health authority.

Secondly and more significantly he said that in 6 months of working in Europe's busiest A and E he only knew of one patient with a bleed to whom the warfarin antidote was administered. In other words, the usual methods of stopping bleeds - pressure etc - worked just as well for anticoaguleted patients as for those who are not. Might take a bit longer, might lose a bit more blood, but basically will get there without antidote.

Interesting I thought...

25 Replies

  • Good to know. thank you for sharing as is a concern of mine with Apixoban.

  • Thank you for posting that, scottishmuppet - I laughed out loud at the fate of poor Moaning Myrtle. The drug companies are currently having reversal agents for the NOAC's validated - one for Pradaxa is the first to be available, I believe.

    The main effect of these agents may be to make the NOACs seem more acceptable to patients and physicians, even though as you say, procedures already exist for dealing with a serious bleed. However, my thinking is that in dealing with a serious bleed, medics will be primarily concerned with existing pressure, plasma and transfusion methods to stabilise the patient. Antidotes, or the lack of them may be a secondary issue as your GP has indicated.

  • Thank you so much for sharing that! I am so glad that people are finally starting to get past the "where is the antidote?" issue! (plus there are some now)! The drugs have a very short half life, plus the usual measures to stop bleeding do not involve antidotes, and think how many medications are used that could possibly have a life threatening effect and there are no antidotes. Maybe it is because my Dad died from complications from a warfarin bleed, but I've been a big fan of the NOAC's from the get go!

  • And in my case it was it was 19 hours after administration of vitimin k that my I.N.R. had gone from 2.5 to 2. Not exactly a quick antidote! X

  • I am being very ignorant here, but perhaps you can help me. Where an antidote might be need for a "significant bleed", are we talking about a bleed caused by an accident, a cut, road accident, or such like?

    As I am newly on Apixoban, should I be looking out for an internal bleed, and would that appear as a "significant bleed' in need of an antidote?

    I hope this makes sense and if it does not I apologise! I am just trying to get all my facts right.

    thank you so much

  • Hi I'm new too so I will leave others more qualified to reply. Other than to say, if you haven't already, read the lengthy note that comes with the prescription it lists all the side effects and warning signs and is a very effective stimulant should you fancy staying awake till dawn 😨

  • Pretty much what we have been saying for a while now. The main risk of course is gastro intestinal bleeds which do not become evident for some time. Best to make sure that you don't get repeated stomach problems or have a gastric ulcer.

  • Thanks Bob but could you just clarify. I do not have stomach probs or an ulcer. how would I know if I had internal bleeding?

    I feel very apprehensive being on these pills apixoban and have read good things, but some awful things too.

    also if you took the meds for lets say 3 months without any problems of bleeding, does that mean you would be stable and never have them? Im guessing not.

    would appreciate your knowledge and experience.

    thank you

  • Most people are on them for life if you have AF - it depends on individual circumstances.

    It is not a treatment per se, it is a preventative treatment - to lessen the risk of severe stroke or MI (heart attack) resulting in a clot forming in the atria getting into the arteries and blocking them whilst in AF or when the heart is converting to NSR, which is also a critical risk time.

    The primary treatment of AF is to prevent or lessen risk of stroke & heart attack - hence the Anti-coagulation - again go to the AFA site and you will find really good information about how/why/when on all these questions.

    I know I am answering for Bob, but I do so because I know he has answered this query so many times and I am attempting to lighten his load. I know he will pick me up if I post anything out of line!

  • it would depend on where you bled from internally- If it was from your digestive tract you would pass blood in in stools- dark colour for an old bleed- red for new. Lungs- might cough up blood stained mucus-Major bleeding internally would make you feel faint, you would look pale, get breathless etc.feel sweaty and generally unwell.

    The general opinion of doctors I have heard talk on this is that we are not at much higher risk than those not on anti-coagulants- one's blood still clots but just a little more slowly. It would only matter is there was severe injury and pressure can normally be applied to stop that sort of bleeding.

    I am on Apixaban and have had no problems at all.

  • When they administered vitamin k to me in A&E a few weeks back it only took it down from 2.3 to 1.8 in 15 hours then they had to give me more vitamin k and overall it took 36 hours to get it down from 2.3 to 1.2 (ie not back to normal even then). Considering half life of apixaban is 12 hours that would have been quicker because the majority would have been out of my system in 24 hours. A few weeks earlier my INR was up at 4.3 so I hate to think how long that would have taken!!! I was told it is not just a question of increasing the dose.

  • OK- Bleeds - read the literature on the AFA website.

    If you are in a bad accident and severed an artery - apply immediate pressure until medics arrive, as you would normally. Ensure you carry on you a card noting that you use ACs or wear a medialert-bracelet.

    Internal bleeds - there are 2 types to be aware of - bleed in the brain which would present similar to a stroke or TIA - you would need a scan to confirm whether it was a bleed or clot - believe me the NOACS will help protect you from the latter - in most of the studies on NOACs v Wafarin, NOACs have a lesser risk of brain bleed than Wafarin but a slightly higher risk of stomach/intestinal bleeds.

    Intestinal bleeds - stomach etc - much, much less than if you take aspirin. You would notice brownish/black blood in your stools. If you are at all concerned you would go immediately to your doctor or A&E. Passing red blood in stool motions is unlikely to be internal bleed, more likely to be piles - but again make an appointment with your GP.

    Most serious internal bleeds result from blunt trauma so if you fall and injure yourself it is always best to get checked.

    Just because you take ACs does not mean you are going to be much more at risk for serious bleeds unless you work in an industry such as agriculture (like Koll) or operate a chain saw or something. Do not be overly concerned but do be aware and don't hesitate to seek medical attention if you are worried about symptoms you suspect to be a bleed.

    The risks are very, very low if your HASBLED score has been deemed low enough for you to be prescribed ACs in the first place.

  • PS - My understanding from my doctors is that the main concern for anyone who is Anti-coagulated would be if you needed emergency surgery - in that case they may well administer the anti-dote for Wararin. They have another procedure to cope with NOACs which is a bit like plasmapheris (a type dialysis process) which they would do in an extreme life/death scenario.

    Everyday cuts and bruises are not considered hazardous or life threatening.

  • If it is truly emergency surgery then I understand that a blood transfusion will be given to speed up as vit k takes too long.

  • If it is a severe case of bleeding when on warfarin, PCC (Prothrombin complex concentrate) is administered as a standard process in the NHS. This reverses the effects in about 10 minutes. Air ambulances are also supplied with it.

  • Hurrah I'm reduntant!

  • You trained us well Bob, we couldn't do it without you! x

  • You will never be redundant BobB. Cannot do without you and your help.

  • Hi scottishmuppet - I've been on apixaban for about 2 years. What does occasionally cross my mind is brain bleeds - especially when I feel a rare (for me) headache coming on. An arterial bleed (in a serious event) can be halted with applying manual (digital) pressure but obviously,this can't be done for a brain bleed or for that matter a gut bleed. Both these bleeds are mentioned as side effects of Apixaban in literature. This is my only concern with Apixaban and other NOAC's.



  • You don't mention warfarin. I thought that the risk of bleeds of some of the NOACs was less then that for warfarin???

  • it is Peter.

  • Hi PeterWh, I can't comment on Warfarin - I have never had it prescribed.



  • I worry about a stroke far more than I worry about a bleed (I am on warfarin). That said, I had a spin on the back of my husband's motor bike on remote tracks in the mountains in southern Spain and when we got home the realisation struck that doing that mightn't have been the brightest thing to do...

    Interestingly, a friend who lives here in Spain full-time had a nasty fall and severely bruised her lower back. She had it checked out at the hospital, nothing broken, but has to inject heparin for the next couple of weeks. Apparently this is standard treatment here for any type of injury that can affect mobility, however slight.

  • As I have Rheumatoid Disease and take medication for this including non-steroidals,methotrexate etc,I take a stomach protector tablet-pantoprozil,I think this may be useful for people taking medication for AF also,to protect against stomach irritation from the drugs used for AF,lessoning the risk of bleeds!

  • my Apixoban tablets are described as being film coated on the packet. would this perhaps be a stomach protector?

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