IV Thrombolysis May Not Add to Hemorrhage Risk in Patients Given DOACs

By David Douglas

January 11, 2020

NEW YORK (Reuters Health) - Intravenous thrombolysis (IVT) seems safe in certain patients with acute ischemic stroke (AIS) who are taking direct oral anticoagulants (DOACs), according to a systematic review and meta-analysis.

"Based on the results of our study, prior intake of direct oral anticoagulants (e.g., apixaban, rivaroxaban) appears not to increase the risk of symptomatic intracerebral hemorrhage among patients with acute ischemic stroke who are treated with intravenous thrombolysis," Dr. Ramin Zand of Geisinger Medical Center, in Danville, Pennsylvania, told Reuters Health by email.

Dr. Zand and colleagues examined reports on the safety of IVT among AIS patients pretreated with DOACs less than 48 hours before tPA (tissue plasminogen activator) bolus and in the absence of reversal agents.

Despite the established benefit and safety of DOACs, the team points out, "there is 1% to 2% annual risk of stroke among these patients." Furthermore, they add, reports suggest more and more patients on DOACs are receiving intravenous thrombolysis.

After reviewing the literature and communicating with the authors of a number of studies, the researchers zeroed in on six studies involving more than 52,000 ischemic stroke patients. Of these, 366 received DOACs and 2,133 received warfarin, while the remainder had received no prior anticoagulation.

People taking DOACs within 48 hours presented no extra risk of symptomatic intracerebral hemorrhage following IVT compared with those taking warfarin or those who had received no prior anticoagulation. Studies in subgroups showed that this was also the case with no time limit between last intake of DOACs and the tPA bolus.

Relying on case reports and case series, the researchers then examined the outcome in 123 individual cases with or without reversal agents before IVT.

There was no significant increase in the risk of hemorrhagic transformation, symptomatic hemorrhagic transformation or early mortality between those who did or did not receive prethrombolysis idarucizumab.

However, the researchers concede that overall there was a "small sample size, lack of randomization and inadequate data regarding the exact time of last DOACs intake.

Thus, concluded Dr. Zand, "There is a need for further studies to confirm the safety of intravenous thrombolysis among patients with acute ischemic stroke who are taking direct oral anticoagulants."

Two of his coauthors report financial ties to drugmakers.

SOURCE: https://bit.ly/2tOopkz Stroke, online December 30, 2019.