Accidental and Surreptitious Intake of Oral Anticoagulants Including Older and Newer Agents - A Diagnostic Dilemma

The newer oral anticoagulants including dabigatran, rivaraxoban, apixaban and edoxaban are replacing warfarin in the management of atrial fibrillation and venous thromboembolism. Accidental and surreptitious overdose of warfarin has been reported, but so far there is no reported case of overdose involving NOACs. Overdose of warfarin prolongs coagulation tests including PT and APTT. This gives a clue as to the underlying cause of bleeding, but with the newer oral anticoagulants these tests are of no value. The diagnosis and management of bleeding with accidental and surreptitious intake of oral anticoagulants is very difficult and high index of suspicion is needed.