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Michael P Gulseth Anticoagulation Consulting, Inc.

Specializing in professional consulting to aid hospitals and health-systems optimize patient outcomes when using anticoagulants and avoid litigation



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Is 4-factor Prothrombin Complex Concentrate (4F-PCC) or Andexxa® Better to Reverse Xa Inhibitor Bleeding?

Posted by gulseth.michael on August 6, 2019 at 1:05 PM Comments comments (1068)

By Jenna Cariddi, Pharm D Student Pharmacist

Edited by Michael P Gulseth, Pharm. D., BCPS, FASHP

A current controversial topic amongst anticoagulation management providers is what is the best agent to use for the reversal of bleeding from oral Xa inhibitors. This is a debatable topic because many anticoagulation reversal guidelines were published prior to the approval of andexanet alfa and because there have been no studies comparing andexanet alfa to other therapies s...

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The Need for Baseline anti-Xa Levels when Monitoring Heparin in the Direct Oral Anticoagulant Era

Posted by gulseth.michael on March 5, 2019 at 6:00 AM Comments comments (2253)

By Michael P Gulseth, Pharm. D., BCPS, FASHP

DOAC to heparin transitions have become one of the more challenging issues in the modern era of anticoagulation management. I am regularly contacted (1-2 times per month) by colleagues for advice how to handle this. While even we don’t have all the answers, we have learned a few things from the literature.

Probably the most important article published on this topic is Macedo KA, et. al....

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Time to Monitor Direct Oral Anticoagulants (DOACs) in Anticoagulation Clinics

Posted by gulseth.michael on September 25, 2018 at 3:45 PM Comments comments (151)

by Shelby Rabenberg, Pharm D Student Pharmacist

Edited by Michael P. Gulseth, Pharm. D., BCPS, FASHP

The scope of anticoagulation therapy is slowly changing due to the emergence of direct oral anticoagulants (DOACs). DOACs eliminate several problems that are seen with warfarin including need for frequent INR monitoring, dietary considerations and pre-operative bridging. Even though routine anticoagulation effect monitoring of DOACs is deemed as unnecessary, there ...

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Should we use fixed dose PCC for the reversal of anticoagulation?

Posted by gulseth.michael on June 20, 2018 at 5:25 PM Comments comments (257)

By Darren R Kueter, Student Pharmacist

Edited by Michael P. Gulseth, Pharm. D., BCPS, FASHP

PCC (prothrombin complex concentrate) is a reversal agent that can be utilized in the event of acute major bleeding or the need for urgent surgery in patients that are taking vitamin K antagonists such as warfarin. PCC does have many advantages over FFP (fresh frozen plasma) for the reversal of bleeding events. These advantages include quicker reconstitution (no th...

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Andexanet Alpha Approval, Where to Begin?

Posted by gulseth.michael on May 10, 2018 at 10:00 AM Comments comments (239)

One thing I love about my job is it never gets boring…….

Unless you live under a rock, I am sure you are aware the first specific reversal agent for factor Xa inhibitors has been approved. The full package insert can be found at:

Now, as an antithrombotic pharmacist, I’ve been following the development of this agent very closely for years. Here is a list of issues I am immensely intereste...

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On Demand CE on Laboratory Issues with DOAC Therapy

Posted by gulseth.michael on April 29, 2017 at 12:40 AM Comments comments (163)

I recently partnered with Stago to create a new, on demand activity talking about contemporary laboratory issues with DOAC therapy.  It is called "Direct Oral Anticoagulant Screening and Measurement for Challenging Patient Cases" and can be found at this link:

I do realize pharmacists cannot get CE for this, but other professionals can.  With that said, these are critical...

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Bariatric surgery and DOACs; what to do?

Posted by gulseth.michael on April 25, 2017 at 2:20 PM Comments comments (2817)

Soon after the advent of direct oral anticoagulation therapy, we were confronted with what should we do in patients with new or history of bariatric surgery.  At our hospital, we quickly moved away from them in this population, but it is a deficient topic that in all of the DOAC package labels.

Thankfully, a recent, excellent review was pulblished on this topic:

Martin KA, Lee CR, Farrell TM, Moll S. Oral Anticoagulant Use After Bariatric Surgery: A Literature Rev...

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DOAC effects on traditional labs

Posted by gulseth.michael on April 25, 2017 at 12:25 AM Comments comments (177)


I keep running into a lack of understanding of the effects of DOACs on traditional labs. I want to summarize, and keep this simple:

Dabigatran will modestly prolong aPTT at therapeutic and high levels. If normal, patient could still have therapeutic levels. Best lab to confirm low dabigatran levels for many is thrombin time. If the thrombin time is measurable or normal, patient likely has very low dabigatran levels.

Rivaroxaban typically causes a significant...

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Heparin Induced Thrombocytopenia (HIT) Care Issues

Posted by gulseth.michael on March 16, 2017 at 7:00 AM Comments comments (0)


HIT; it is the anticoagulation topic that you must know if you practice in hospitals in anticoagulation. I never cease to be amazed by the errors and mistakes that can happen when caring for HIT patients. I just want to pass along a few tips based on practical experience:

1. PF4 antibody testing is great if you remember it is very sensitive, but not very specific. Why? It tests for antibodies that bind to heparin/PF4 complexes. So, if the test is negative, you likely ...

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Monday Morning Patient Care Thoughts

Posted by gulseth.michael on March 13, 2017 at 11:50 AM Comments comments (677)


While waiting for a doctor to call back so I can stop an un-needed heparin drip, I felt like writing a few miscellaneous thoughts on my mind:


1. We had another rivaroxaban to heparin transition yesterday. In this case, patient had acute PE and went into AKI while on rivaroxaban. 36 hours after a last dose of rivaroxaban, they drew a rivaroxaban level. It was 201 ng/ml, likely at a therapeutic level. Patient had a chest tube placed at that time (the reas...

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