Dabigatran, rivaroxaban and apixaban are oral anticoagulants used to prevent or 
treat thrombosis in a variety of situations. Like all anticoagulants, these 
drugs can provoke bleeding. How should patients be managed if bleeding occurs 
during dabigatran, rivaroxaban or apixaban therapy? How can the risk of bleeding 
be reduced in patients who require surgery or other invasive procedures? To 
answer these questions, we reviewed the available literature, using the standard 
Prescrire methodology. In clinical trials, warfarin, enoxaparin, dabigatran, 
rivaroxaban and apixaban were associated with a similar frequency of severe 
bleeding. Numerous reports of severe bleeding associated with dabigatran have 
been recorded since this drug was first marketed. Some situations are associated 
with a particularly high bleeding risk, including: even mild renal failure, 
advanced age, extremes in body weight and drug-drug interactions, particularly 
with antiplatelet agents (including aspirin), nonsteroidal antiinflammatory 
drugs, and many drugs used in cardiovascular indications. In patients treated 
with dabigatran, rivaroxaban or apixaban, changes in the INR (international 
normalised ratio) and activated partial thromboplastin time (aPTT) do not 
correlate with the dose. In early 2013, there is still no routine coagulation 
test suitable for monitoring these patients; specific tests are only available 
in specialised laboratories. In early 2013 there is no antidote for dabigatran, 
rivaroxaban or apixaban, nor any specific treatment with proven efficacy for 
severe bleeding linked to these drugs. Recommendations on the management of 
bleeding in this setting are based mainly on pharmacological parameters and on 
scarce experimen-Haemodialysis reduces the plasma concentration of dabigatran, 
while rivaroxaban and apixaban cannot be eliminated by dialysis. Prothrombin 
complex concentrates and recombinant activated factor VII seem to have little or 
no efficacy, and they carry a poorly documented risk of thrombosis. For patients 
undergoing surgery or other invasive procedures, clinical practice guidelines 
are primarily based on pharmacokinetic parameters and on extrapolation of data 
on vitamin K antagonists. The decision on whether or not to discontinue 
anticoagulation before the procedure mainly depends on the likely risk of 
bleeding. In patients at high risk of thrombosis, heparin can be proposed when 
the anticoagulant is withdrawn. In early 2013, difficulties in the management of 
bleeding and of situations in which there is a risk of bleeding weigh heavily in 
the balance of potential harm versus potential benefit of dabigatran, 
rivaroxaban and apixaban. When an oral anticoagulant is required, it is best to 
choose warfarin, a vitamin K antagonist, and the drug with which we have the 
most experience, except in those rare situations in which the INR cannot be 
maintained within the therapeutic range.