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Simioni P, Cipriano A, D'Angelo A, Giannasi G, Ricci G, Campello E, Susi B, Andreone V, Candelaresi P. The efficacy and safety of andexanet alfa in the treatment of anticoagulation-related major bleedings: An Italian perspective. Thromb Res 2024; 245:109241. [PMID: 39700713 DOI: 10.1016/j.thromres.2024.109241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2024] [Revised: 12/04/2024] [Accepted: 12/08/2024] [Indexed: 12/21/2024]
Affiliation(s)
- Paolo Simioni
- Department of Medicine (DIMED), University of Padua, Padua, Italy; General Internal Medicine Unit, Padua University-Hospital, Padua, Italy
| | - Alessandro Cipriano
- Emergency Department, Nuovo Santa Chiara Hospital, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Armando D'Angelo
- Coagulation Service and Thrombosis Research Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Gianfranco Giannasi
- Emergency Medicine Unit, Ospedale San Giovanni di Dio, Emergency Department of Azienda USL Toscana Centro, Florence, Italy
| | - Giorgio Ricci
- Poison Control Center of Verona, Integrated University Hospital of Verona, Verona, Italy
| | - Elena Campello
- Department of Medicine (DIMED), University of Padua, Padua, Italy; General Internal Medicine Unit, Padua University-Hospital, Padua, Italy
| | - Beniamino Susi
- S. Paolo Hospital, Civitavecchia (RM) - ASL, Roma 4, Italy
| | | | - Paolo Candelaresi
- Neurology and Stroke Unit, AORN "Antonio Cardarelli", Naples, Italy.
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2
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Rodrigues A, Gonçalves LR, Gregório T, Baldaia C, Santo GC, Gouveia J. Urgent Reversal of Direct Oral Anticoagulants in Critical and Life-Threatening Bleeding: A Multidisciplinary Expert Consensus. J Clin Med 2024; 13:6842. [PMID: 39597986 PMCID: PMC11595216 DOI: 10.3390/jcm13226842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2024] [Revised: 11/08/2024] [Accepted: 11/11/2024] [Indexed: 11/29/2024] Open
Abstract
Direct oral anticoagulants (DOACs) are increasingly being used due to their improved efficacy/safety ratio and lower clinical and economic burden when compared to vitamin K antagonists. However, bleeding is still the most frequent complication associated with DOACs, and although rare, bleeding episodes can be life-threatening or critical. The impact of DOAC anticoagulation activity during a bleeding event must be evaluated according to patient clinical assessment, dosage and time from last intake, the presence of comorbidities (especially kidney and liver dysfunction), and, whenever possible, coagulation tests. Unfortunately, DOACs' anticoagulation activity is not easily or usually detectable in routine common coagulation testing. Specific DOAC tests allow for specific drug monitoring, but they are too time consuming, and are usually unavailable in routine emergency practice. If a clinically relevant DOAC plasma concentration is assumed or proven in a severe bleeding scenario, DOAC reversal is needed to restore hemostasis. This experts' consensus provides a narrative review about DOAC reversal and practical life-threatening bleeding management in several scenarios (trauma, intracranial hemorrhage and gastrointestinal bleeding), focusing on the selection of patients to whom specific reversal agents should be given.
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Affiliation(s)
- Anabela Rodrigues
- Serviço de Imuno-Hemoterapia, Unidade Local de Saúde (ULS) Santa Maria, 1649-028 Lisboa, Portugal
| | - Luciana Ricca Gonçalves
- Serviço de Imuno-Hemoterapia, Unidade Local de Saúde (ULS) São João, 4200-319 Porto, Portugal;
| | - Tiago Gregório
- Serviço de Medicina Interna e Unidade AVC, Unidade Local de Gaia e Espinho, 4434-502 Vila Nova de Gaia, Portugal;
- CINTESIS—Centro de Investigação em Tecnologias e Serviços de Saúde, 4200-450 Porto, Portugal
| | - Cilénia Baldaia
- Serviço de Medicina Intensiva, Unidade Local de Saúde (ULS) Santa Maria, 1649-028 Lisboa, Portugal; (C.B.); (J.G.)
- Serviço de Gastroenterologia, Unidade Local de Saúde (ULS) Santa Maria, 1649-028 Lisboa, Portugal
- Clínica Universitária de Gastrenterologia, Faculdade de Medicina de Lisboa, 1649-028 Lisboa, Portugal
| | - Gustavo C. Santo
- Serviço de Neurologia, Hospitais da Universidade de Coimbra, Unidade Local de Saúde (ULS) de Coimbra, 3004-561 Coimbra, Portugal;
- Center for Innovative Biomedicine and Biotechnology (CiBB), Universidade de Coimbra, 3004-561 Coimbra, Portugal
| | - João Gouveia
- Serviço de Medicina Intensiva, Unidade Local de Saúde (ULS) Santa Maria, 1649-028 Lisboa, Portugal; (C.B.); (J.G.)
- Clínica Universitária de Medicina Intensiva, Faculdade de Medicina de Lisboa, 1649-028 Lisboa, Portugal
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Sarhan K, Mohamed RG, Elmahdi RR, Mohsen Y, Elsayed A, Zayed DM, Elkholi MA, Gabr N, El-Bialy EM, Serag I. Efficacy and Safety of Andexanet Alfa Versus Four Factor Prothrombin Complex Concentrate for Emergent Reversal of Factor Xa Inhibitor Associated Intracranial Hemorrhage: A Systematic Review and Meta-Analysis. Neurocrit Care 2024:10.1007/s12028-024-02130-y. [PMID: 39379749 DOI: 10.1007/s12028-024-02130-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2024] [Accepted: 09/06/2024] [Indexed: 10/10/2024]
Abstract
Factor Xa inhibitors (FXaI) are increasingly used for anticoagulation therapy, yet their association with intracranial hemorrhage poses a significant challenge. Although andexanet alfa (AA) and four-factor prothrombin complex concentrate (4F-PCC) have shown promise in reversing FXaI effects, their comparative efficacy and safety remain uncertain. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we conducted a literature search on electronic databases to obtain the relevant studies until May 16, 2024. Our primary outcomes were successful anticoagulation reversal, overall mortality (including 30-day and in-hospital mortality), and thromboembolic events. Secondary outcomes were length of hospital and intensive care unit stay and hematoma volume expansion. Data were pooled using a random-effects model. We included 16 eligible studies with a total of 2,977 patients. A statistically significant improvement in hemostatic efficacy rates was in favor of the AA group (risk ratio [RR] 1.10, 95% confidence interval [CI] 1.01-1.20, P = 0.02). Lower overall mortality rates were found in the AA group (RR 0.67, 95% CI 0.51-0.88, P = 0.004). However, no difference was found in 30-day mortality rates (RR 0.82, 95% CI 0.58-1.16, P = 0.26). In terms of thromboembolic events, more events were found in the AA group (RR 1.47, 95% CI 1.01-2.15, P = 0.046). AA was associated with a longer duration of hospital stay compared to 4F-PCC (mean difference [MD] 0.64, 95% CI 0.07-1.22, P = 0.03). Neither a significant difference in length of intensive care unit stay (MD 0.25, 95% CI - 0.36 to 0.86, P = 0.41) nor a significant difference in hematoma volume expansion was reported (MD - 0.89, 95% CI - 3.11 to 1.34, P = 0.435). Our results suggest that AA is superior to 4F-PCC in enhancing the hemostatic efficacy and reducing the overall and in-hospital mortality rates. More thromboembolic events are thought to be associated with the use of AA. However, more studies are required to validate whether the better results of AA in improving hemostatic efficacy are enough to make up for their higher cost and their possible risk of thromboembolic events.
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Affiliation(s)
- Khalid Sarhan
- Faculty of Medicine, Mansoura University, Mansoura, Egypt.
| | - Rashad G Mohamed
- Mansoura Manchester Program for Medical Education, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Reem Reda Elmahdi
- Mansoura Manchester Program for Medical Education, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Youstina Mohsen
- Mansoura Manchester Program for Medical Education, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Asmaa Elsayed
- Mansoura Manchester Program for Medical Education, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Dania Mosaad Zayed
- Mansoura Manchester Program for Medical Education, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Menna A Elkholi
- Mansoura Manchester Program for Medical Education, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Nagat Gabr
- Mansoura Manchester Program for Medical Education, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Enjy M El-Bialy
- Mansoura Manchester Program for Medical Education, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Ibrahim Serag
- Faculty of Medicine, Mansoura University, Mansoura, Egypt
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Levy JH, Shaw JR, Castellucci LA, Connors JM, Douketis J, Lindhoff-Last E, Rocca B, Samama CM, Siegal D, Weitz JI. Reversal of direct oral anticoagulants: guidance from the SSC of the ISTH. J Thromb Haemost 2024; 22:2889-2899. [PMID: 39029742 DOI: 10.1016/j.jtha.2024.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2024] [Revised: 07/04/2024] [Accepted: 07/08/2024] [Indexed: 07/21/2024]
Abstract
The currently approved direct oral anticoagulants (DOACs) are increasingly used in clinical practice. Although serious bleeding risks are lower with DOACs than with vitamin K antagonists, bleeding remains the most frequent side effect. Andexanet alfa and idarucizumab are the currently approved specific reversal agents for oral factor (F)Xa inhibitors and dabigatran, respectively. Our prior guidance document was published in 2016, but with more information available on the utility and increased use of these reversal agents and other bleeding management strategies, we have updated this International Society on Thrombosis and Haemostasis guidance document on DOAC reversal. In this narrative review, we compare the mechanism of action of specific and nonspecific reversal agents, review the clinical data supporting their use, and provide guidance on when reversal is indicated. In addition, we briefly discuss the reversal of oral FXIa inhibitors, a new class of DOACs currently under clinical development.
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Affiliation(s)
- Jerrold H Levy
- Department of Anesthesiology, Critical Care, and Surgery, Duke University School of Medicine, Durham, North Carolina, USA.
| | - Joseph R Shaw
- Department of Medicine, Division of Hematology, University of Ottawa, Ottawa, Ontario, Canada
| | - Lana A Castellucci
- Department of Medicine, Ottawa Hospital Research Institute at the University of Ottawa, Ottawa, Ontario, Canada
| | - Jean M Connors
- Hematology Division Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - James Douketis
- Department of Medicine, Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Edelgard Lindhoff-Last
- Department of Vascular Medicine and Hemostaseology, Coagulation Research Centre Bethanien Hospital, Frankfurt, Germany
| | - Bianca Rocca
- Department of Safety and Bioethics-Section of Pharmacology, Catholic University School of Medicine, Rome, Italy; NeuroFarBa Department, University of Florence, Florence, Italy
| | - Charles Marc Samama
- Department of Anaesthesia, Intensive Care and Perioperative Medicine, Groupement Hospitalier Universitaire Assistance Publique - Hôpitaux de Paris Centre, Université Paris Cité, Paris, France
| | - Deborah Siegal
- Department of Medicine, Ottawa Hospital Research Institute at the University of Ottawa, Ottawa, Ontario, Canada
| | - Jeffrey I Weitz
- Departments of Medicine and Biochemistry and Biomedical Sciences, McMaster University and the Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada
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Alikhan R, Nour M, Yasaka M, Ofori-Asenso R, Axelsson-Chéramy S, Chen H, Seghal V, Yokobori S, Koch B, Tiede A, Cash BD, Maegele M, Singer AJ. Design and rationale for REVERXaL: A real-world study of patients with factor Xa inhibitor-associated major bleeds. Thromb Res 2024; 240:109046. [PMID: 38905928 DOI: 10.1016/j.thromres.2024.109046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Revised: 05/22/2024] [Accepted: 05/28/2024] [Indexed: 06/23/2024]
Abstract
BACKGROUND The prevalence of anticoagulation treatment is increasing as an aging global population faces a high burden of cardiovascular comorbidities. Direct oral anticoagulants, including factor Xa inhibitors (FXai), are replacing vitamin K antagonists as the most commonly prescribed treatment for reducing risk of thrombotic events. While the risk of FXai-associated spontaneous bleeds is established, less is understood about their management and the effect of treatment on clinical and patient-reported outcomes. The primary objectives of the REVERXaL study are to describe patient characteristics, health care interventions during the acute-care phase, in-hospital outcomes, and associations between timing of reversal/replacement agent administration and in-hospital outcomes. Secondary/exploratory objectives focus on clinical assessments and patient-reported outcome measures (PROMs) at 30 and 90 days. METHODS REVERXaL is a multinational, observational study of hospitalized patients with FXai-associated major bleeds in Germany, Japan, the United Kingdom, and the United States. The study includes 2 cohorts of approximately 2000 patients each. Cohort A is a historic cohort for whom medical chart data will be collected from hospitalization to discharge for patients admitted for major bleeds during FXai use within 2 years prior to enrollment of Cohort B. Cohort B will prospectively enroll patients administered any reversal/replacement agent during hospitalization to manage FXai-associated major bleeds and will include the collection of clinical outcomes and PROMs data over 3 months. CONCLUSIONS REVERXaL will generate insights on patient characteristics, treatment approaches, and associated outcomes in patients hospitalized with FXai-associated major bleeds. These data may inform clinical practice and streamline treatment pathways in this population. REGISTRATION URL: https://www. CLINICALTRIALS gov; unique identifier: NCT06147830.
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Affiliation(s)
- Raza Alikhan
- University Hospital of Wales and Cardiff University School of Medicine, Cardiff, Wales, United Kingdom.
| | - May Nour
- University of California, Los Angeles, California, United States
| | | | | | | | - Hungta Chen
- AstraZeneca, Wilmington, Delaware, United States
| | - Vinay Seghal
- University College London Hospital, London, United Kingdom
| | | | - Bruce Koch
- AstraZeneca, Wilmington, Delaware, United States
| | | | - Brooks D Cash
- University of Texas Health Science Center at Houston, Houston, Texas, United States
| | - Marc Maegele
- Cologne-Merheim Medical Center, Cologne, Germany
| | - Adam J Singer
- Stony Brook University, New York, New York, United States
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6
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Orso D, Fonda F, Brussa A, Comisso I, Auci E, Sartori M, Bove T. Andexanet alpha versus four-factor prothrombin complex concentrate in DOACs anticoagulation reversal: an updated systematic review and meta-analysis. Crit Care 2024; 28:221. [PMID: 38970010 PMCID: PMC11225147 DOI: 10.1186/s13054-024-05014-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2024] [Accepted: 07/01/2024] [Indexed: 07/07/2024] Open
Abstract
BACKGROUND There is currently a lack of evidence for the comparative effectiveness of Andexanet alpha and four-factor prothrombin complex concentrate (4F-PCC) in anticoagulation reversal of direct oral anticoagulants (DOACs). The primary aim of our systematic review was to verify which drug is more effective in reducing short-term all-cause mortality. The secondary aim was to determine which of the two reverting strategies is less affected by thromboembolic events. METHODS A systematic review and meta-analysis was performed. RESULTS Twenty-two studies were analysed in the systematic review and quantitative synthesis. In all-cause short-term mortality, Andexanet alpha showed a risk ratio (RR) of 0.71(95% CI 0.37-1.34) in RCTs and PSMs, compared to 4F-PCC (I2 = 81%). Considering the retrospective studies, the pooled RR resulted in 0.84 (95% CI 0.69-1.01) for the common effects model and 0.82 (95% CI 0.63-1.07) for the random effects model (I2 = 34.2%). Regarding the incidence of thromboembolic events, for RCTs and PSMs, the common and the random effects model exhibited a RR of 1.74 (95% CI 1.09-2.77), and 1.71 (95% CI 1.01-2.89), respectively, for Andexanet alpha compared to 4F-PCC (I2 = 0%). Considering the retrospective studies, the pooled RR resulted in 1.21 (95% CI 0.87-1.69) for the common effects model and 1.18 (95% CI 0.86-1.62) for the random effects model (I2 = 0%). CONCLUSION Considering a large group of both retrospective and controlled studies, Andexanet alpha did not show a statistically significant advantage over 4F-PCC in terms of mortality. In the analysis of the controlled studies alone, Andexanet alpha is associated with an increased risk of thromboembolic events. CLINICAL TRIAL REGISTRATION PROSPERO: International prospective register of systematic reviews, 2024, CRD42024548768.
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Affiliation(s)
- Daniele Orso
- Azienda Sanitaria Universitaria Friuli Centrale, Department of Emergency "Santa Maria Della Misericordia", University Hospital of Udine, Piazzale Santa Maria Della Misericordia, N.15, 33100, Udine, UD, Italy.
- Department of Medicine, University of Udine, via Colugna 50, 33100, Udine, Italy.
| | - Federico Fonda
- Azienda Sanitaria Universitaria Friuli Centrale, Department of Emergency "Santa Maria Della Misericordia", University Hospital of Udine, Piazzale Santa Maria Della Misericordia, N.15, 33100, Udine, UD, Italy
| | - Alessandro Brussa
- Azienda Sanitaria Universitaria Friuli Centrale, Department of Emergency "Santa Maria Della Misericordia", University Hospital of Udine, Piazzale Santa Maria Della Misericordia, N.15, 33100, Udine, UD, Italy
| | - Irene Comisso
- Azienda Sanitaria Universitaria Friuli Centrale, Department of Emergency "Santa Maria Della Misericordia", University Hospital of Udine, Piazzale Santa Maria Della Misericordia, N.15, 33100, Udine, UD, Italy
| | - Elisabetta Auci
- Azienda Sanitaria Universitaria Friuli Centrale, Department of Emergency "Santa Maria Della Misericordia", University Hospital of Udine, Piazzale Santa Maria Della Misericordia, N.15, 33100, Udine, UD, Italy
| | - Marco Sartori
- Azienda Sanitaria Universitaria Friuli Centrale, Department of Emergency "Santa Maria Della Misericordia", University Hospital of Udine, Piazzale Santa Maria Della Misericordia, N.15, 33100, Udine, UD, Italy
| | - Tiziana Bove
- Azienda Sanitaria Universitaria Friuli Centrale, Department of Emergency "Santa Maria Della Misericordia", University Hospital of Udine, Piazzale Santa Maria Della Misericordia, N.15, 33100, Udine, UD, Italy
- Department of Medicine, University of Udine, via Colugna 50, 33100, Udine, Italy
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Conti A, Leorin M, Bogazzi IC, Renzi N, Pepe G, Frosini F, Furesi L, Dalla Tomasina L, Pennati P, Ghiadoni L. Reversal or Repletion Treatment Strategies and Outcomes of Patients With Major Bleeding Events Managed in the Emergency Department: Large Real-Life Investigation in the Northwestern Healthcare District of Tuscany. Crit Pathw Cardiol 2024; 23:58-72. [PMID: 38781079 DOI: 10.1097/hpc.0000000000000360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
OBJECTIVE To verify the incidence of bleeding events in patients on ongoing anticoagulant treatment in the real world and compare the results of different reversal or repletion strategies currently available for pharmacological treatment. METHODS Patients managed in the emergency department (ED) with major bleeding events, on ongoing anticoagulation were stratified according to bleeding site and reversal or repletion therapy with andexanet alfa (ADX), idarucizumab (IDA), prothrombin complex concentrate (PCC), and vitamin K (Vit-K). ENDPOINT Death at 30 days was compared in the subgroups with cerebral hemorrhage (CH) and gastrointestinal (GI) bleeding. RESULTS Of the 809,397 visits in the years 2022-2023 at 6 EDs in the northwestern health district of Tuscany, 5372 patients with bleeding events were considered; 3740 were excluded due to minor bleeding or propensity score matching. Of the remaining 1632 patients with major bleeding, 548 on ongoing anticoagulation were enrolled; 334 received reversal or repletion agents. Patients with CH (n = 176) and GI bleeding (n = 108) represented the primary analysis cohorts in the study's strategic treatment assessment. Overall, 30-day survival of patients on ongoing aFXa treatment receiving on-label ADX versus off-label PCC showed a relative increase of 71%, while 30-day survival of patients on ongoing aFII receiving on-label IDA versus off-label PCC showed a relative increase of 30%; no substantial difference was found when comparing on-label PCC combined with Vit-K versus off-label Vit-K alone. Indeed, patients undergoing on-label ADX or IDA showed a statistically significant difference over off-label PCC (ADX vs. PCC: n = 15, events = 4, mean ± SD 82.50 ± 18.9, vs. 49, 13, 98.82 ± 27, respectively; analysis of variance [ANOVA] variance 8627; P < 0.001; posthoc test diff 32, 95% confidence interval: 28-35; P < 001; IDA vs. PCC: 20, 5, 32.29 ± 15.0 vs. 2, 1, 28.00 ± 0.0, respectively; ANOVA 1484; P < 0.001; posthoc test -29, -29 -29, respectively; P = n.d.). On-label PCC combined with Vit-K showed overall a slight statistically significant difference versus off-label Vit-K alone (52, 16, 100.58 ± 22.6 vs. 53, 11, 154.62 ± 29.8, respectively; ANOVA 310; P < 0.02; posthoc test 4, 0.7-7.2, respectively; P < 0.02). Data were confirmed in the group of patients with CH (ADX vs. PCC: n = 13, events = 3, mean ± SD 91.55 ± 18.6 vs. 78, 21, 108.91 ± 20.9, respectively; ANOVA variance 10,091, F = 261; P < 0.001; posthoc difference test 36, 95% confidence interval: 30-41; P < 0.001; IDA vs. PCC: 10, 2, 4.50 ± 2.5 vs. 78, 21, 108.91 ± 20.9, respectively; ANOVA 16,876,303, respectively; P < 0.001; posthoc test 41, 34-47, respectively; P < 0.001). On-label PCC combined with Vit-K showed an overall slight statistically significant difference compared with off-label Vit-K alone (P < 0.01 and P < 0.001 in the subgroups of CH and GI bleeding). CONCLUSIONS Patients undergoing specific reversal therapy with on-label ADX or IDA, when treated with aFXa or aFII anticoagulants, respectively, showed statistically elevated differences in 30-day death compared with off-label repletion therapy with PCC. Overall, 30-day survival of patients on ongoing aFXa or aFII receiving on-label reversal therapy with ADX or IDA compared with off-label PCC repletion agents showed an increase of 71% and 30%, respectively.
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Affiliation(s)
- Alberto Conti
- From the Emergency Department, Apuane General Hospital, Massa-Carrara, Italy
| | - Marco Leorin
- From the Emergency Department, Apuane General Hospital, Massa-Carrara, Italy
| | | | - Noemi Renzi
- From the Emergency Department, Apuane General Hospital, Massa-Carrara, Italy
| | - Giuseppe Pepe
- Emergency Department, Versilia and San Luca Hospital, Lucca, Italy
| | - Fabiana Frosini
- Emergency Department, Versilia and San Luca Hospital, Lucca, Italy
| | - Lucilla Furesi
- Emergency Department, Pontedera, Livorno and Cecina Hospital, Livorno, Italy
| | - Luca Dalla Tomasina
- Emergency Department, Pontedera, Livorno and Cecina Hospital, Livorno, Italy
| | - Paolo Pennati
- Emergency Department, Pontedera, Livorno and Cecina Hospital, Livorno, Italy
| | - Lorenzo Ghiadoni
- Emergency Medicine, University of Pisa, Cisanello University Hospital, Pisa, Italy
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8
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White CM, Caroti KS, Bessada Y, Hernandez AV, Baker WL, Dobesh PP, van Haalen H, Rhodes K, Coleman CI. Andexanet alfa versus PCC products for factor Xa inhibitor bleeding: A systematic review with meta-analysis. Pharmacotherapy 2024; 44:394-408. [PMID: 38721837 DOI: 10.1002/phar.2925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 04/12/2024] [Accepted: 04/12/2024] [Indexed: 06/11/2024]
Abstract
Previous meta-analyses assessed andexanet alfa (AA) or prothrombin complex concentrate (PCC) products for the treatment of Factor Xa inhibitor (FXaI)-associated major bleeding. However, they did not include recent studies or assess the impact of the risk of bias. We conducted a systematic review with meta-analysis on the effectiveness of AA versus PCC products for FXaI-associated major bleeding, inclusive of the studies' risk of bias. PubMed and Embase were searched for comparative studies assessing major bleeding in patients using FXaI who received AA or PCC. We used the Methodological Index for NOn-Randomized Studies (MINORS) checklist and one question from the Joanna Briggs Institute (JBI) Critical Appraisal of Case Series tool to assess the risk of bias. Random-effects meta-analyses were performed to provide a pooled estimate for the effect of AA versus PCC products on hemostatic efficacy, in-hospital mortality, 30-day mortality, and thrombotic events. Low-moderate risk of bias studies were meta-analyzed separately, as well as combined with high risk of bias studies. Eighteen comparative evaluations of AA versus PCC were identified. Twenty-eight percent of the studies (n = 5) had low-moderate risk and 72% (n = 13) had a high risk of bias. Studies with low-moderate risk of bias suggested improvements in hemostatic efficacy [Odds Ratio (OR) 2.72 (95% Confidence Interval (CI): 1.15-6.44); one study], lower in-hospital mortality [OR 0.48 (95% CI: 0.38-0.61); three studies], and reduced 30-day mortality [OR 0.49 (95% CI: 0.30-0.80); two studies] when AA was used versus PCC products. When studies were included regardless of the risk of bias, pooled effects showed improvements in hemostatic efficacy [OR 1.36 (95% CI: 1.01-1.84); 12 studies] and reductions in 30-day mortality [OR 0.53 (95% CI: 0.37-0.76); six studies] for AA versus PCC. The difference in thrombotic events with AA versus PCC was not statistically significant in the low-moderate, high, or combined risk of bias groups. The evidence from low-moderate quality real-world studies suggests that AA is superior to PCC in enhancing hemostatic efficacy and reducing in-hospital and 30-day mortality. When studies are assessed regardless of the risk of bias, the pooled hemostatic efficacy and 30-day mortality risk remain significantly better with AA versus PCC.
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Affiliation(s)
- C Michael White
- University of Connecticut School of Pharmacy, Storrs, Connecticut, USA
- Hartford Hospital Health Outcomes, Policy and Evidence Synthesis Group, Hartford, Connecticut, USA
| | - Kimberly Snow Caroti
- University of Connecticut School of Pharmacy, Storrs, Connecticut, USA
- Hartford Hospital Health Outcomes, Policy and Evidence Synthesis Group, Hartford, Connecticut, USA
| | - Youssef Bessada
- University of Connecticut School of Pharmacy, Storrs, Connecticut, USA
| | - Adrian V Hernandez
- University of Connecticut School of Pharmacy, Storrs, Connecticut, USA
- Hartford Hospital Health Outcomes, Policy and Evidence Synthesis Group, Hartford, Connecticut, USA
- Unidad de Revisiones Sistemáticas y Meta-análisis (URSIGET), Vicerrectorado de Investigación, Universidad San Ignacio de Loyola, Lima, Peru
| | - William L Baker
- University of Connecticut School of Pharmacy, Storrs, Connecticut, USA
- Hartford Hospital Health Outcomes, Policy and Evidence Synthesis Group, Hartford, Connecticut, USA
| | - Paul P Dobesh
- University of Nebraska Medical Center College of Pharmacy, Omaha, Nebraska, USA
| | | | - Kirsty Rhodes
- Medical and Payer Evidence, BioPharmaceuticals Medical, AstraZeneca, Cambridge, UK
| | - Craig I Coleman
- University of Connecticut School of Pharmacy, Storrs, Connecticut, USA
- Hartford Hospital Health Outcomes, Policy and Evidence Synthesis Group, Hartford, Connecticut, USA
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Buka RJ, Sutton DJ, Nicolson PL. Enoxaparin is not an oral factor Xa inhibitor. Response to Sutton et al. real-world clinical outcomes among US veterans with oral factor Xa inhibitor-related major bleeding treated with andexanet alfa or 4-factor prothrombin complex concentrate. J Thromb Thrombolysis 2024; 57:739-741. [PMID: 38358568 DOI: 10.1007/s11239-024-02948-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/04/2024] [Indexed: 02/16/2024]
Affiliation(s)
- Richard J Buka
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK.
| | - David J Sutton
- Staffordshire Thrombosis and Anticoagulation Service, University Hospitals North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Phillip Lr Nicolson
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
- Department of Clinical Haematology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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De Luca L, Pugliese FR, Susi B, Navazio A, Corda M, Fabbri A, Scicchitano P, Voza A, Vanni S, Bilato C, Geraci G, Gabrielli D, Grimaldi M, Colivicchi F, De Iaco F, Oliva F. ANMCO/SIMEU consensus document on the use of reversal agents for antithrombotic therapies in patients with ongoing bleeding or at high risk of haemorrhagic events. Eur Heart J Suppl 2024; 26:ii211-ii220. [PMID: 38784674 PMCID: PMC11110459 DOI: 10.1093/eurheartjsupp/suae033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
In recent decades, an incredible evolution in antithrombotic therapies used for treating patients with atherosclerosis, atrial fibrillation, and venous thromboembolism has been observed, leading to the availability of increasingly safe drugs. Nonetheless, bleeding complications remain a significant concern, with considerable health, social, and economic implications. To improve the acute management of patients experiencing or at risk for major bleeding events, specific reversal agents for antithrombotic drugs have been recently developed. While these agents demonstrate effectiveness in small-scale pharmacodynamic studies and clinical trials, it is imperative to balance the benefits of reversing antiplatelet or anticoagulant therapy against the risk of prothrombotic effects. These risks include the potential loss of antithrombotic protection and the prothrombotic tendencies associated with bleeding, major surgery, or trauma. This joint document of the Italian Association of Hospital Cardiologists (Associazione Nazionale Medici Cardiologi Ospedalieri) and the Italian Society of Emergency Medicine (Società Italiana di Medicina d'Emergenza-Urgenza) delineates the key features and efficacy of available reversal agents. It also provides practical flowcharts to guide their use in patients with active bleeding or those at elevated risk of major bleeding events.
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Affiliation(s)
- Leonardo De Luca
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Viale Camillo Golgi 19, 27100 Pavia, Italy
| | | | - Beniamino Susi
- Dipartimento di Emergenza, Policlinico Tor Vergata, Rome, Italy
| | - Alessandro Navazio
- S.O.C. Cardiologia Ospedaliera, Presidio Ospedaliero Arcispedale Santa Maria Nuova, Azienda USL di Reggio Emilia—IRCCS, Reggio Emilia, Italy
| | - Marco Corda
- S.C. Cardiologia, Azienda Ospedaliera G. Brotzu, Cagliari, Italy
| | - Andrea Fabbri
- Dipartimento di Emergenza, AUSL Romagna, Presidio Ospedaliero Morgagni-Pierantoni, Forlì, Italy
| | | | - Antonio Voza
- Dipartimento di Scienze Biomediche, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Simone Vanni
- Dipartimento Medicina Sperimentale e Clinica, Università degli Studi di Firenze, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Claudio Bilato
- U.O.C. Cardiologia, Ospedali dell’Ovest Vicentino, Azienda ULSS 8 Berica, Vicenza, Italy
| | - Giovanna Geraci
- U.O.C. Cardiologia, Ospedale Sant’Antonio Abate, Trapani, Italy
| | - Domenico Gabrielli
- Dipartimento Cardio-Toraco-Vascolare, U.O.C. Cardiologia, Azienda Ospedaliera San Camillo Forlanini, Roma, Italy
| | - Massimo Grimaldi
- U.O.C. Cardiologia-UTIC, Ospedale Miulli, Acquaviva delle Fonti, Italy
| | - Furio Colivicchi
- U.O.C. Cardiologia Clinica e Riabilitativa, Presidio Ospedaliero San Filippo Neri—ASL Roma 1, Rome, Italy
| | - Fabio De Iaco
- S.C. Medicina di Emergenza-Urgenza, Ospedale Maria Vittoria, ASL Città di Torino, Turin, Italy
| | - Fabrizio Oliva
- Unità di Cure Intensive Cardiologiche, Cardiologia 1-Emodinamica, Dipartimento Cardiotoracovascolare ‘A. De Gasperis’, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
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11
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Frol S, Oblak JP, Šabovič M, Kermer P. Andexanet Alfa: What We Have Learned from Clinical Trials and Real-World Data. CNS Drugs 2024; 38:163-168. [PMID: 38396232 DOI: 10.1007/s40263-024-01071-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/06/2024] [Indexed: 02/25/2024]
Abstract
Andexanet alfa is a specific reversal agent for factor Xa inhibitors with immediate reversal of their anticoagulant effect. Andexanet alfa is currently approved for use in patients treated with rivaroxaban and apixaban who have life-threatening or uncontrolled bleeding. New data from both controlled clinical trials and real-world experience are continuously being published, providing greater insight into the clinical characteristics of the drug, such as efficacy and safety. It is worth considering that andexanet alfa could be of benefit in a variety of different clinical scenarios where patients receiving treatment with apixaban and rivaroxaban (and endoxaban) have life-threatening conditions. These different clinical scenarios, which range from pre-treatment of urgent surgery, especially neurosurgical interventions, and concomitant use of andexanet alfa and prothrombin complex concentrate to onset of bleeding more than 6 h prior to admission, should be clarified as well as the issue of "low/high" dose of andexanet alfa and the need for baseline anti-Xa inhibitor levels measured by point-of-care testing. Finally, management of patients at high risk of thrombosis or recent arterial/venous thrombotic events needs to be further explored. In this current opinion, we address these urgent questions in the light of recent literature and clinical trial data.
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Affiliation(s)
- Senta Frol
- Department of Vascular Neurology, University Medical Center Ljubljana, Ljubljana, Slovenia.
- Faculty of Medicine, University of Ljubljana, Zaloška 2, 1000, Ljubljana, Slovenia.
| | - Janja Pretnar Oblak
- Department of Vascular Neurology, University Medical Center Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Zaloška 2, 1000, Ljubljana, Slovenia
| | - Mišo Šabovič
- Department of Vascular Disorders, University Medical Center Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Zaloška 2, 1000, Ljubljana, Slovenia
| | - Pawel Kermer
- Department of Neurology, Nordwest-Krankenhaus Sanderbusch, Friesland Kliniken GmbH, Sande, Germany
- University Medical Center, Göttingen, Germany
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12
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Andexanet alfa for reversal of direct factor Xa inhibitor anticoagulation. Aust Prescr 2024; 47:31-32. [PMID: 38444895 PMCID: PMC10911831 DOI: 10.18773/austprescr.2024.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2024] Open
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13
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Dobesh PP, Fermann GJ, Christoph MJ, Koch B, Lesén E, Chen H, Lovelace B, Dettling T, Danese M, Ulloa J, Danese S, Coleman CI. Lower mortality with andexanet alfa vs 4-factor prothrombin complex concentrate for factor Xa inhibitor-related major bleeding in a U.S. hospital-based observational study. Res Pract Thromb Haemost 2023; 7:102192. [PMID: 37753225 PMCID: PMC10518480 DOI: 10.1016/j.rpth.2023.102192] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 07/28/2023] [Accepted: 07/30/2023] [Indexed: 09/28/2023] Open
Abstract
Background Well-designed studies with sufficient sample size comparing andexanet alfa vs 4-factor prothrombin complex concentrate (4F-PCC) in routine clinical practice to evaluate clinical outcomes are limited. Objectives To compare in-hospital mortality in patients hospitalized with rivaroxaban- or apixaban-related major bleeding who were treated with andexanet alfa or 4F-PCC. Methods An observational cohort study (ClinicalTrials.gov identifier: NCT05548777) was conducted using electronic health records between May 2018 and September 2022 from 354 U.S. hospitals. Inclusion criteria were age ≥18 years, inpatient admission with diagnosis code D68.32 (bleeding due to extrinsic anticoagulation), a record of use of the factor Xa inhibitors rivaroxaban or apixaban, andexanet alfa or 4F-PCC treatment during index hospitalization, and a documented discharge disposition. Multivariable logistic regression on in-hospital mortality with andexanet alfa vs 4F-PCC was performed. The robustness of the results was assessed via a supportive propensity score-weighted logistic regression. Results The analysis included 4395 patients (andexanet alfa, n = 2122; 4F-PCC, n = 2273). There were 1328 patients with intracranial hemorrhage (ICH), 2567 with gastrointestinal (GI) bleeds, and 500 with critical compartment or other bleed types. In the multivariable analysis, odds of in-hospital mortality were 50% lower for andexanet alfa vs 4F-PCC (odds ratio [OR], 0.50; 95% CI, 0.39-0.65; P < .01) and were consistent for both ICH (OR, 0.55; [0.39-0.76]; P < .01) and GI bleeds (OR, 0.49 [0.29-0.81]; P = .01). Similar results were obtained from the supporting propensity score-weighted logistic regression analyses. Conclusion In this large observational study, treatment with andexanet alfa in patients hospitalized with rivaroxaban- or apixaban-related major bleeds was associated with 50% lower odds of in-hospital mortality than 4F-PCC. The magnitude of the risk reduction was similar in ICH and GI bleeds.
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Affiliation(s)
- Paul P. Dobesh
- University of Nebraska Medical Center, College of Pharmacy, Omaha, Nebraska, USA
| | - Gregory J. Fermann
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | | | | | | | | | | | | | - Mark Danese
- Outcomes Insights, Agoura Hills, California, USA
| | - Julie Ulloa
- Outcomes Insights, Agoura Hills, California, USA
| | | | - Craig I. Coleman
- University of Connecticut School of Pharmacy, Storrs, Connecticut, USA
- Evidence-based Practice Center, Hartford Hospital, Hartford, Connecticut, USA
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14
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Sutton SS, Magagnoli J, Cummings TH, Dettling T, Lovelace B, Christoph MJ, Hardin JW. Correction to: Real-world clinical outcomes among US Veterans with oral factor xa inhibitor-related major bleeding treated with andexanet alfa or 4-factor prothrombin complex concentrate. J Thromb Thrombolysis 2023:10.1007/s11239-023-02841-7. [PMID: 37306840 DOI: 10.1007/s11239-023-02841-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/01/2023] [Indexed: 06/13/2023]
Affiliation(s)
- S Scott Sutton
- Dorn Research Institute, Columbia VA Healthcare System (151), 6439 Garners Ferry Road, Columbia, SC, 29209, USA.
- Department of Clinical Pharmacy and Outcomes Sciences, College of Pharmacy, University of South Carolina, Columbia, SC, USA.
| | - Joseph Magagnoli
- Dorn Research Institute, Columbia VA Healthcare System (151), 6439 Garners Ferry Road, Columbia, SC, 29209, USA
- Department of Clinical Pharmacy and Outcomes Sciences, College of Pharmacy, University of South Carolina, Columbia, SC, USA
| | - Tammy H Cummings
- Dorn Research Institute, Columbia VA Healthcare System (151), 6439 Garners Ferry Road, Columbia, SC, 29209, USA
- Department of Clinical Pharmacy and Outcomes Sciences, College of Pharmacy, University of South Carolina, Columbia, SC, USA
| | - Theresa Dettling
- Global Health Economics and Outcomes Research, AstraZeneca Rare Disease, Alexion, USA
| | - Belinda Lovelace
- Global Health Economics and Outcomes Research, AstraZeneca Rare Disease, Alexion, USA
| | - Mary J Christoph
- Global Health Economics and Outcomes Research, AstraZeneca Rare Disease, Alexion, USA
| | - James W Hardin
- Dorn Research Institute, Columbia VA Healthcare System (151), 6439 Garners Ferry Road, Columbia, SC, 29209, USA
- Department of Epidemiology and Biostatistics, University of South Carolina, 6439 Garners Ferry Road, Columbia, SC, 29209, USA
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