New anticoagulants and the management of their bleeding complications

SUMMARY Limitations of the currently available anticoagulants have fanned the continuing search for new anticoagulants with improved pharmacological and biosafety profile, and equal, if not superior efficacy. Targets of inhibition include the factor VIIa/tissue factor pathway (recombinant nematode anticoagulant peptide c2, tissue factor pathway inhibitor), factor Xa (fondaparinux, idraparinux, razaxaban), factor Va and VIIIa pathway (recombinant activated protein C, soluble thrombomodulin) and thrombin (hirudin, bivalirudin, argatroban, ximelagatran, dabigatran). Irrespective of their mode of action, bleeding complications are invariable with all anticoagulants. Conventional assessment and measures should remain as first‐line responses to bleeding complicating the use of these anticoagulants. Antidotes do not exist for the overwhelming majority of these agents. The role of recombinant activated factor VIIa in controlling bleeding is still investigational. Definitive haemostatic strategies for bleeding complications can only evolve with accumulating experience with these new agents.