Three target-specific oral anticoagulants (TSOACs)-dabigatran, rivaroxaban, and 
apixaban-have been approved by the FDA to reduce the risk of stroke and systemic 
embolism in patients with nonvalvular atrial fibrillation; however, no agents 
are currently approved to reverse the anticoagulant effects of these TSOACs in 
cases of active bleeding. This review discusses the benefits and risks of these 
TSOACs from a clinician's perspective, with a focus on the interruption of 
treatment for either elective or emergent surgery, monitoring, and reversal of 
anticoagulation. Available coagulation assays are not ideal for monitoring the 
effects of TSOACs and do not provide reliable quantitative measurement of their 
anticoagulant effects. When necessary, activated partial thromboplastin time 
(aPTT) may provide qualitative information on dabigatran, and prothrombin time 
(PT) may provide qualitative assessment of the presence of the factor Xa 
inhibitors, rivaroxaban and apixaban. Current recommendations for reversal of 
TSOACs are based largely on limited and sometimes conflicting data from in vitro 
or in vivo animal models, and clinical experience with these recommendations is 
also limited. Methods that have been investigated for effectiveness for reversal 
of the pharmacodynamic effects of the TSOACs include dialysis, activated 
charcoal, prothrombin complex concentrate (PCC), and recombinant activated 
factor VII. It is important to note that even within a class of anticoagulant 
drugs, compounds respond differently to reversal agents; therefore, 
recommendations for one agent should not be extrapolated to another, even if 
they are from the same therapeutic class. New antidotes are being explored, 
including a mouse monoclonal antibody to dabigatran; andexanet alfa, a potential 
universal factor Xa inhibitor reversal agent; and a synthetic small molecule 
(PER977) that may be effective for the reversal of factor Xa inhibitors and 
direct thrombin inhibitors. Given the short half-lives of TSOACs, watchful 
waiting, rather than reversal, may be the best approach in some circumstances.