American Society of Hirudotherapy

Diagnostics and management of direct oral anticoagulants-induced bleeding

Review published in Current opinion in anaesthesiology (2025)

Last Updated: June 18, 2026Reviewed by: ASH Editorial Board
Research article — evidence reviewArticle reference
Evidence: Narrative reviewClinical TrialsSafety & Infection Controlvon Heymann C et al. · Current opinion in anaesthesiology, 2025

Abstract

PURPOSE OF REVIEW: To provide evidence-based management of patients on direct oral anticoagulants (DOAC) needing acute procedures, including those facing hemorrhage. RECENT FINDINGS: Standard coagulation parameters are insufficient for precise DOAC plasma level measurement; calibrated anti factor X activated assays are reliable, and point-of-care assays may be useful in urgent situations. For intracerebral hemorrhage (ICH) in patients on DOACs, direct reversal strategies seem to be more effective than nonspecific hemostatic agents, but evidence still remains unclear in terms of efficacy and safety compared to nonspecific hemostatic agents. Before invasive procedures like neuraxial anesthesia or cerebral thrombectomy, idarucizumab is recommended for dabigatran-treated patients, despite recent observational data not fully supporting this. No recommendations can be made for FXa inhibitors because of the lack of data. SUMMARY: Clinicians should assess the overall risk of bleeding for an acute procedure or the severity of any ongoing hemorrhage in DOAC-treated patients before initiating any reversal treatment, regardless of current evidence levels.

Abstract sourced from PubMed (NCBI) for the cited record. See the original publication for the authoritative version.

Publication typeJournal ArticleReview
Indexed MeSH termsHumansAnticoagulantsAdministration, OralHemorrhageFactor Xa InhibitorsDabigatranCerebral HemorrhageAntibodies, Monoclonal, HumanizedBlood Coagulation Tests

Summary

To provide evidence-based management of patients on direct oral anticoagulants (DOAC) needing acute procedures, including those facing hemorrhage.

Why This Matters for Hirudotherapy

This review examines evidence-based management of patients on direct oral anticoagulants (DOACs) requiring acute procedures or facing hemorrhage, including laboratory monitoring approaches and reversal strategies. The topic is relevant to ASH/hirudotherapy because dabigatran—one of the DOACs discussed—is a direct thrombin inhibitor in the same mechanistic class as hirudin, the anticoagulant derived from medicinal leeches. The review reports that calibrated anti-factor Xa assays are reliable for DOAC measurement, direct reversal strategies for intracerebral hemorrhage may be more effective than nonspecific agents, and idarucizumab is recommended for dabigatran-treated patients before invasive procedures like neuraxial anesthesia or cerebral thrombectomy. However, this is a narrative review, and the authors note that evidence remains unclear regarding the efficacy and safety of direct reversal compared to nonspecific hemostatic agents.

Citation

Diagnostics and management of direct oral anticoagulants-induced bleeding

von Heymann C et al. · Current opinion in anaesthesiology, 2025

DOI

Added to ASH library: May 27, 2026 · Site last updated: June 18, 2026

This website provides educational information and does not constitute medical advice, diagnosis, or treatment recommendations. Medicinal leech therapy carries clinically meaningful risks and should be performed only by qualified clinicians under institutionally approved protocols. FDA 510(k) clearance for medicinal leeches is limited to specific indications; investigational and off-label discussions are labeled accordingly. For patient-specific guidance, consult a qualified healthcare provider.