Managing bleeding in anticoagulated patients with a focus on novel therapeutic agents

Heparin, low molecular weight heparin (LMWH) and coumarins are familiar to most clinicians, inexpensive, highly effective when correctly used and widely available. However, coumarin has a delayed onset of action, interacts with many medications, has a narrow therapeutic window, and can cause thrombosis in some settings (e.g. hereditary protein C deficiency, heparin induced thrombocytopenia, warfarin loading). Additionally, warfarin and heparin require monitoring of their therapeutic effect. These real and perceived limitations have led to the development of 'novel' anticoagulants. However, these new agents have one general limitation - a lack of a widely available antidote. We focus on the management of bleeding in anticoagulated patients, with particular regard to novel anticoagulants.