see also [[Warfarin, DOAC, heparin reversal]], [[Warfarin overdose]] - [Austin DOAC guideline](x-devonthink-item://6B53FA9A-D69B-415B-92C2-E37047ACC096) > [!key points] > - single ingestions of higher than normal doses of apixaban or rivaroxaban usually uncomplicated course in an otherwise well patient > - they exhibit a ==ceiling effect due to receptor saturation== > - are *cleared* from circulation reasonably quickly # Coagulation profile | parameter | dabigitran <br>(thrombin inhibitor) | rivaroxaban / apixaban<br>(Xa inhibitors) | | ------------------------------------ | ------------------------------------------------------------------------------------------------------------ | ----------------------------------------- | | INR | mild ↑ | variable | | aPTT | prolonged but not ∝ drug concentration<br>aPTT > 90s suggests ↑ drug level | variable | | thrombin clotting time <br>(TT, TCT) | very sensitive<br>normal values exclude presence of drug<br>exceeds measurement times at high concentrations | not useful at all | | haemoclot assay | can help derive levels | not useful | | Factor IIa (thrombin) assay | best ∝ with bleeding risk | not useful | | Factor Xa assay | not useful | good ∝ with levels | # management of over anticoagulation - usually in setting of serious haemorrhage rather than overdose - best practice unclear - establish *exact time last dose was given* - cease agent consider [[Decontamination#activated charcoal]] if drug taken in previous - 2 hours for dabigatran - 6 hr for apixaban - 8 hr for rivaroxaban - [[Prothrombinex]] - at least 70% effective in reversal of rivaroxaban and apixaban - less effective for dabigatran - most likely of use if INR is elevated - [[TXA]] - [[haemodialysis]] for dabigatrain toxicity (not useful for rivaroxaban or apixaban) - idraucizumab (praxbind) for dabigatran - andexanet alfa (Andexxa) for rivaroxaban and dabigatran if life-threatening bleeding - hydration to help enhance renal clearance of rivaroxaban