UMEM Educational Pearls

Category: Pharmacology & Therapeutics

Title: tPA Use in Patients on New Oral Anticoagulants: Recommendations from the 2013 Ischemic Stroke Guidelines

Keywords: alteplase, tPA, dabigatran, anticoagulant, apixaban, rivaroxaban (PubMed Search)

Posted: 4/3/2013 by Bryan Hayes, PharmD (Emailed: 4/6/2013) (Updated: 4/5/2013)
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A new recommendation in the 2013 Ischemic Stroke Guidelines provides guidance on what to do in patients taking new oral anticoagulants who are deemed eligible for IV fibrinolysis. Here is what the guidelines say:

"The use of IV rtPA in patients taking direct thrombin inhibitors (dabigatran) or direct factor Xa inhibitors (rivaroxaban, apixaban) may be harmful and is not recommended unless sensitive laboratory tests such as aPTT, INR, platelet count, and ECT, TT, or appropriate direct factor Xa activity assays are normal, or the patient has not received a dose of these agents for >2 days (assuming normal renal metabolizing function)." (Class III; Level of Evidence C)
Additional points:
  • The most helpful lab tests are not widely available.
  • A detailed history is important, but not always obtainable.

Until further data are available, a history consistent with recent use of new oral anticoagulants generally precludes use of IV tPA.


Jauch EC, et al. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2013;44(3):870-947. PMID 23370205

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