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Meinig R, Jarvis S, Salottolo K, Nwafo N, McNair P, Harrison P, Morgan S, Duane T, Woods B, Nentwig M, Kelly M, Cornutt D, Bar-Or D. Propensity matched analysis examining the effect of passive reversal of direct oral anticoagulants on blood loss and the need for transfusions among traumatic geriatric hip fractures. Eur J Med Res 2023; 28:241. [PMID: 37475008 PMCID: PMC10360353 DOI: 10.1186/s40001-023-01053-2] [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: 02/01/2022] [Accepted: 02/08/2023] [Indexed: 07/22/2023] Open
Abstract
BACKGROUND Reversal of direct oral anticoagulants (DOACs) is currently recommended prior to emergent surgery, such as surgical intervention for traumatic geriatric hip fractures. However, reversal methods are expensive and timely, often delaying surgical intervention, which is a predictor of outcomes. The study objective was to examine the effect of DOAC reversal on blood loss and transfusions among geriatric patients with hip fractures. METHODS This retrospective propensity-matched study across six level I trauma centers included geriatric patients on DOACs with isolated fragility hip fractures requiring surgical intervention (2014-2017). Outcomes included: intraoperative blood loss, intraoperative pRBCs, and hospital length of stay (HLOS). RESULTS After matching there were 62 patients (31 reversed, 31 not reversed), 29 patients were not matched. The only reversal method utilized was passive reversal (waiting ≥ 24 hours for elimination). Passively reversed patients had a longer time to surgery (mean, 43 vs. 18 hours, p < 0.01). Most patients (92%) had blood loss (90% passively reversed, 94% not reversed); the median volume of blood loss was 100 mL for both those groups, p = 0.97. Thirteen percent had pRBCs transfused (13% passively reversed and 13% not reversed); the median volume of pRBCs transfused was 525 mL for those passively reversed and 314 mL for those not reversed, p = 0.52. The mean HLOS was significantly longer for those passively reversed (7 vs. 5 days, p = 0.001). CONCLUSIONS Passive DOAC reversal for geriatric patients with isolated hip fracture requiring surgery may be contributing to delayed surgery and an increased HLOS without having a significant effect on blood loss or transfusions. These data suggest that passive DOAC reversal may not be necessary prior to surgical repair of isolated hip fracture.
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Affiliation(s)
- Richard Meinig
- Penrose Hospital, 2222 N Nevada Ave, Colorado Springs, CO, 80907, USA
| | - Stephanie Jarvis
- Injury Outcomes Network (ION) Research, 501 East Hampden Ave, Englewood, CO, 80113, USA
| | - Kristin Salottolo
- Injury Outcomes Network (ION) Research, 501 East Hampden Ave, Englewood, CO, 80113, USA
| | - Nnamdi Nwafo
- Swedish Medical Center, 501 East Hampden Ave, Englewood, CO, 80113, USA
| | - Patrick McNair
- St. Anthony Hospital, 11600 W 2nd Plaza, Lakewood, CO, 80228, USA
| | - Paul Harrison
- Wesley Medical Center, 550 North Hillside St. Wichita, Wichita, KS, 67214, USA
| | - Steven Morgan
- Swedish Medical Center, 501 East Hampden Ave, Englewood, CO, 80113, USA
| | - Therese Duane
- Medical City Plano, 3901 West 15th Street, Plano, TX, 75075, USA
| | - Bradley Woods
- Research Medical Center, 2316 East Meyer Blvd, Kansas City, MO, 64132, USA
| | - Michelle Nentwig
- Wesley Medical Center, 550 North Hillside St. Wichita, Wichita, KS, 67214, USA
| | - Michael Kelly
- Penrose Hospital, 2222 N Nevada Ave, Colorado Springs, CO, 80907, USA
| | - David Cornutt
- Regional West Medical Center, 4021 Ave B, Scottsbluff, NE, 69361, USA
| | - David Bar-Or
- Injury Outcomes Network (ION) Research, 501 East Hampden Ave, Englewood, CO, 80113, USA.
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Mild Head Trauma (MHT) and Antiplatelet Therapy. Reply to Lorenzati et al. Comment on "Savioli et al. Mild Head Trauma: Is Antiplatelet Therapy a Risk Factor for Hemorrhagic Complications? Medicina 2021, 57, 357". MEDICINA-LITHUANIA 2021; 57:medicina57090889. [PMID: 34577811 PMCID: PMC8469365 DOI: 10.3390/medicina57090889] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 08/13/2021] [Accepted: 08/23/2021] [Indexed: 11/17/2022]
Abstract
We read your data with interest, and we truly appreciate the similar experience [...].
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Different Coagulation Indicators in Predicting Clinical Outcomes for Patients With Direct Oral Anticoagulants: A Systematic Review and Meta-analysis. Clin Ther 2020; 42:2066-2081.e9. [PMID: 32900534 DOI: 10.1016/j.clinthera.2020.08.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 06/18/2020] [Accepted: 08/03/2020] [Indexed: 11/23/2022]
Abstract
PURPOSE There are many anticoagulant test indexes available for direct oral anticoagulants (DOACs), but how to select the appropriate index and the index cutoff values are still controversial. This is the first study, to our knowledge, to assess the association of different coagulation indicators with clinical outcomes among DOACs using a meta-analysis of observational studies. METHODS A medical literature search was conducted using PubMed, Web of Science, EMBASE, ClinicalTrials.gov, and the Cochrane Library from inception to February 2020. Studies that reported relationships between coagulation indexes and clinical outcomes or the diagnostic value of coagulation assays were included in the analysis. FINDINGS A total of 17 articles (7 meta-analyses and 10 systematic reviews) from 8904 citations were included in the analysis. In the analysis of bleeding events with coagulation indexes for DOACs, for peak prothrombin time level (cutoff value of 19-25 s), the pooled results found a sensitivity of 0.61 (95% CI, 0.44-0.75) and a specificity of 0.71 (95% CI, 0.49-0.86). For rivaroxaban, the trough anti-factor Xa concentration (AXA-C) (cutoff value of 400-500 ng/mL) had a sensitivity of 0.53 (95% CI, 0.16-0.87) and a specificity of 0.87 (95% CI, 0.71-0.94), with a diagnostic odds ratio of 7 (95% CI, 2-32). For apixaban, trough AXA-C had a sensitivity of 0.85 (95% CI, 0.60-0.96) and a specificity of 0.83 (95% CI, 0.52-0.95). The AUC of the AXA-C peak was higher than that of the trough AXA-C for apixaban, with a higher sensitivity and specificity. Compared with trough concentration of anti-factor IIa for dabigatran, the peak concentration had a higher specificity (98%) at the cutoff value of 484 ng/mL. In the analysis of thromboembolic events with coagulation indexes for DOACs, peak and trough prothrombin time values were not typically correlated with subsequent symptomatic venous thromboembolism, without a sensitivity or specificity higher than 90%. Trough AXA-C had a sensitivity of 100% and but a low specificity (<50%) for rivaroxaban-apixaban. Trough AXA-C had a sensitivity of 100% and a specificity of 32% with a cutoff value of 108 ng/mL for dabigatran. IMPLICATION Peak prothrombin time (19-25 s) and AXA-C had a better predictive value on bleeding outcomes for rivaroxaban and apixaban, whereas peak concentration of anti-factor IIa activity can be an indicator for dabigatran. Coagulation indexes might not be a good indicator of thromboembolic events of DOACs. Because the limited studies focused on association of coagulation indicators and clinical outcomes, more studies are needed to verify this in the future.
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Savioli G, Ceresa IF, Luzzi S, Gragnaniello C, Giotta Lucifero A, Del Maestro M, Marasco S, Manzoni F, Ciceri L, Gelfi E, Ricevuti G, Bressan MA. Rates of Intracranial Hemorrhage in Mild Head Trauma Patients Presenting to Emergency Department and Their Management: A Comparison of Direct Oral Anticoagulant Drugs with Vitamin K Antagonists. MEDICINA (KAUNAS, LITHUANIA) 2020; 56:E308. [PMID: 32585829 PMCID: PMC7353902 DOI: 10.3390/medicina56060308] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 06/17/2020] [Accepted: 06/19/2020] [Indexed: 12/18/2022]
Abstract
Background and objectives: Anticoagulants are thought to increase the risks of traumatic intracranial injury and poor clinical outcomes after blunt head trauma. The safety of using direct oral anticoagulants (DOACs) compared to vitamin K antagonists (VKAs) after intracranial hemorrhage (ICH) is unclear. This study aims to compare the incidence of post-traumatic ICH following mild head injury (MHI) and to assess the need for surgery, mortality rates, emergency department (ED) revisit rates, and the volume of ICH. Materials and Methods: This is a retrospective, single-center observational study on all patients admitted to our emergency department for mild head trauma from 1 January 2016, to 31 December 2018. We enrolled 234 anticoagulated patients, of which 156 were on VKAs and 78 on DOACs. Patients underwent computed tomography (CT) scans on arrival (T0) and after 24 h (T24). The control group consisted of patients not taking anticoagulants, had no clotting disorders, and who reported an MHI in the same period. About 54% in the control group had CTs performed. Results: The anticoagulated groups were comparable in baseline parameters. Patients on VKA developed ICH more frequently than patients on DOACs and the control group at 17%, 5.13%, and 7.5%, respectively. No significant difference between the two groups was noted in terms of surgery, intrahospital mortality rates, ED revisit rates, and the volume of ICH. Conclusions: Patients with mild head trauma on DOAC therapy had a similar prevalence of ICH to that of the control group. Meanwhile, patients on VKA therapy had about twice the ICH prevalence than that on the control group or patients on DOAC, which remained after correcting for age. No significant difference in the need for surgery was determined; however, this result must take into account the very small number of patients needing surgery.
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Affiliation(s)
- Gabriele Savioli
- Emergency Department, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy; (I.F.C.); (L.C.); (E.G.); (M.A.B.)
- Department of Clinical-Surgical, PhD School in Experimental Medicine, Diagnostic and Pediatric Sciences, University of Pavia, 27100 Pavia, Italy;
| | - Iride Francesca Ceresa
- Emergency Department, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy; (I.F.C.); (L.C.); (E.G.); (M.A.B.)
| | - Sabino Luzzi
- Neurosurgery Unit, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, 27100 Pavia, Italy; (S.L.); (A.G.L.); (S.M.)
- Neurosurgery Unit, Department of Surgical Sciences, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
| | - Cristian Gragnaniello
- Department of Neurological Surgery, University of Illinois at Chicago, Chicago, IL 60656, USA;
| | - Alice Giotta Lucifero
- Neurosurgery Unit, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, 27100 Pavia, Italy; (S.L.); (A.G.L.); (S.M.)
| | - Mattia Del Maestro
- Department of Clinical-Surgical, PhD School in Experimental Medicine, Diagnostic and Pediatric Sciences, University of Pavia, 27100 Pavia, Italy;
- Neurosurgery Unit, Department of Surgical Sciences, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
| | - Stefano Marasco
- Neurosurgery Unit, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, 27100 Pavia, Italy; (S.L.); (A.G.L.); (S.M.)
| | - Federica Manzoni
- Clinical Epidemiology and Biometry Unit, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy;
| | - Luca Ciceri
- Emergency Department, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy; (I.F.C.); (L.C.); (E.G.); (M.A.B.)
| | - Elia Gelfi
- Emergency Department, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy; (I.F.C.); (L.C.); (E.G.); (M.A.B.)
| | - Giovanni Ricevuti
- Department of Drug Science, University of Pavia, Italy, -Saint Camillus International University of Health Sciences-Rome-Italy, 27100 Pavia, Italy;
| | - Maria Antonietta Bressan
- Emergency Department, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy; (I.F.C.); (L.C.); (E.G.); (M.A.B.)
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Intake of NOAC is associated with hematoma expansion of intracerebral hematomas after traumatic brain injury. Eur J Trauma Emerg Surg 2019; 47:565-571. [PMID: 31529164 DOI: 10.1007/s00068-019-01228-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Accepted: 09/03/2019] [Indexed: 02/05/2023]
Abstract
PURPOSE Novel oral anticoagulants are increasingly replacing vitamin K antagonists in the prophylaxis of thromboembolism as they are associated with lower incidence of spontaneous intracerebral hematomas and they do not require drug level monitoring. However, management dilemmas are apparent in patients on novel oral anticoagulants who have developed intracerebral hematomas after traumatic brain injury, since clinical experience with their reversal strategies is limited. METHODS We retrospectively studied 90 patients with traumatic intracerebral hematomas undergoing treatment at the surgical intensive care unit of the BG University Clinic Bergmannsheil in Bochum between 2015 and 2018. We analyzed potential prognostic factors for their radiological (expansion of intracerebral hematoma) and clinical (patients' outcome) course, in particular the role of novel oral anticoagulants. RESULTS 71.1% of patients were male; mean age was 67.3 years. Hematoma's expansion occurred in 35.9% of our patients, whereas 62.2% of our cohort showed a favorable outcome, defined as Glasgow Outcome Scale 4 and 5. Intake of novel oral anticoagulants was associated with a higher rate of hematoma's expansion compared to patients on vitamin K antagonists (p = 0.05) or to patients with normal coagulation status (p = 0.002). A younger age (p < 0.001) was identified as the sole independent prognostic factor for a more favorable outcome, after excluding our cases, who underwent a cardiopulmonary resuscitation. CONCLUSIONS Our data showed a higher rate of hematoma's expansion in patients with traumatic intracerebral hematomas on novel oral anticoagulants vs. vitamin K antagonists and recommend the consideration of prophylactic reversal of the novel oral anticoagulants at admission. Larger prospective trials are warranted to conclude whether the current specific reversal protocols are safe and effective.
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Desai NR, Cornutt D. Reversal agents for direct oral anticoagulants: considerations for hospital physicians and intensivists. Hosp Pract (1995) 2019; 47:113-122. [PMID: 31317796 DOI: 10.1080/21548331.2019.1643728] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Direct oral anticoagulants (DOACs) include dabigatran etexilate, a direct thrombin inhibitor, and specific inhibitors of activated coagulation factor X (FXa; e.g. apixaban, betrixaban, edoxaban, rivaroxaban). DOACs are associated with lower rates of major and fatal bleeding events compared with warfarin. Clinicians may need to achieve rapid reversal of anticoagulation effects of the DOACs in an emergency setting. Idarucizumab and andexanet alfa, which reverse the anticoagulant effects of dabigatran and FXa inhibitors, respectively, are DOAC reversal agents available in the US. Other reversal agents (e.g. ciraparantag for heparins, DOACs) are in development. Alternative nonspecific agents (e.g. fresh frozen plasma, prothrombin complex concentrate) are available. Nonspecific prohemostatic agents can counteract the anticoagulant action of DOACs in emergency situations, when specific reversal agents are unavailable. However, specific reversal agents are efficacious and safe and should be preferred when available. In this review, we discuss practical issues in the initiation of DOAC therapy, situations where reversal may be needed, coagulation assays, reversal agents, and post-reversal complications in the context of published evidence and guidelines.
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Affiliation(s)
- Nihar R Desai
- Center for Outcomes Research and Evaluation, Yale-New Haven Health System , New Haven , CT , USA.,Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine , New Haven , CT , USA
| | - David Cornutt
- Department of Emergency Medicine, Regional West Medical Center , Scottsbluff , NE , USA
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Management of Head Trauma in the Neurocritical Care Unit. Neurocrit Care 2019. [DOI: 10.1017/9781107587908.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Cocero N, Basso M, Grosso S, Carossa S. Direct Oral Anticoagulants and Medical Comorbidities in Patients Needing Dental Extractions: Management of the Risk of Bleeding. J Oral Maxillofac Surg 2018; 77:463-470. [PMID: 30347201 DOI: 10.1016/j.joms.2018.09.024] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2017] [Revised: 09/19/2018] [Accepted: 09/19/2018] [Indexed: 01/09/2023]
Abstract
PURPOSE The purpose of this study was to measure the frequency of bleeding during and after tooth extraction in patients exposed to direct oral anticoagulants (DOACs) and identify risk factors for prolonged or excessive bleeding. MATERIALS AND METHODS This retrospective cohort study involved 100 patients who underwent tooth extractions according to the European Heart Rhythm Association protocol: continuation of DOAC therapy for extractions of up to 3 teeth in the same session performed at the (presumed) time of DOAC trough concentration. We respected an interval of at least 4 hours between extraction and last DOAC intake. The outcome of interest was incidence of mild, moderate, and severe bleeding during the intervention and in the 7-day follow-up period. Data analysis considered the presence of comorbidities as the primary predictor for bleeding; additional predictors were age, gender, type of comorbidity, indication for DOAC therapy, DOAC agent, and extraction of contiguous teeth. RESULTS Of the patients, 64 had comorbidities (diabetes in 50%). The distributions of demographic, clinical, and dental variables were similar for patients with and without comorbidities. We observed 4 bleeding episodes (1 moderate episode 1 hour after the extraction and 3 mild episodes the day after the extraction) in the comorbidity group and none in the non-comorbidity group (4 of 64 vs 0 of 36, P = .29; overall bleeding rate, 4 of 100). The factor significantly triggering bleeding in patients with comorbidity was extractions of couples and triplets of multirooted teeth (P = .004). CONCLUSIONS Tooth extractions in patients with comorbidities taking DOACs may be safely managed as long as they are performed at least 4 hours after the last DOAC intake and do not involve 2 or 3 contiguous premolars and molars.
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Affiliation(s)
- Nadia Cocero
- Senior Consultant, Oral Surgery Section, Dental School, University of Torino, Azienda Ospedaliera Città della Salute e della Scienza of Torino, Turin, Italy.
| | - Michele Basso
- Senior Consultant, Oral Surgery Section, Dental School, University of Torino, Azienda Ospedaliera Città della Salute e della Scienza of Torino, Turin, Italy
| | - Simona Grosso
- Junior Consultant, Oral Surgery Section, Dental School, University of Torino, Azienda Ospedaliera Città della Salute e della Scienza of Torino, Turin, Italy
| | - Stefano Carossa
- Department Head, Department of Surgical Sciences, Dental School, University of Torino, Turin, Italy
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Dabi A, Koutrouvelis AP. Reversal Strategies for Intracranial Hemorrhage Related to Direct Oral Anticoagulant Medications. Crit Care Res Pract 2018; 2018:4907164. [PMID: 30073093 PMCID: PMC6057345 DOI: 10.1155/2018/4907164] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2017] [Revised: 05/13/2018] [Accepted: 05/31/2018] [Indexed: 12/16/2022] Open
Abstract
Direct oral anticoagulants (DOACs) are a new class of anticoagulants that directly inhibit either thrombin or factor Xa in the coagulation cascade. They are being increasingly used instead of warfarin or other vitamin K antagonists (VKAs). Adverse side effects of DOACs may result in hemorrhagic complications, including life-threatening intracranial hemorrhage (ICH), though to a much lesser degree than VKAs. Currently there are relatively limited indications for DOACS but their usage is certain to expand with the availability of their respective specific reversal agents. Currently, only idarucizumab (antidote for dabigatran) has been United States Food and Drug Administration- (FDA-) approved, but others (andexanet-α and ciraparantag) may be approved in near future, and the development and availability of such reversal agents have the potential to dramatically change the current anticoagulant use by providing reversal of multiple oral anticoagulants. Until all the DOACs have FDA-approved reversal agents, the treatment of the dreaded side effects of bleeding is challenging. This article is an attempt to provide an overview of the management of hemorrhage, especially ICH, related to DOAC use.
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Affiliation(s)
- Alok Dabi
- Neurosciences Critical Care Program, University of Texas Medical Branch (UTMB), Galveston, TX 77555, USA
| | - Aristides P. Koutrouvelis
- Department of Anesthesiology, Anesthesiology Critical Care Medicine, Surgical and Trauma Intensive Care Unit, Galveston, TX 77555, USA
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Abstract
Oral Factor Xa (FXa) inhibitors, a growing class of direct-acting anticoagulants, are frequently used to prevent stroke and systemic embolism in patients with atrial fibrillation and to prevent and treat venous thromboembolism. These drugs reduce the risk of clotting at the expense of increasing the risk of bleeding, and currently they have no specific reversal agent. However, andexanet alfa, a recombinant modified FXa decoy molecule, is in a late-phase clinical trial in bleeding patients, and ciraparantag, a small molecule that appears to reverse many anticoagulants including the FXa inhibitors, is in development. This review summarizes the published data to date on both drugs, which have the potential to change the management approach to patients with FXa inhibitor-associated major hemorrhage.
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Affiliation(s)
- Truman J Milling
- Departments of Neurology and Surgery and Perioperative Care, Seton Dell Medical School Stroke Institute Austin, Tex
| | - Scott Kaatz
- Division of Hospital Medicine, Henry Ford Hospital, Detroit, MI.
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Milling TJ, Kaatz S. Preclinical and clinical data for factor Xa and "universal" reversal agents. Am J Emerg Med 2016; 34:39-45. [PMID: 27697443 PMCID: PMC5568758 DOI: 10.1016/j.ajem.2016.09.052] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Revised: 08/31/2016] [Accepted: 09/01/2016] [Indexed: 02/06/2023] Open
Abstract
Oral Factor Xa (FXa) inhibitors, a growing class of direct-acting anticoagulants, are frequently used to prevent stroke and systemic embolism in patients with atrial fibrillation and to prevent and treat venous thromboembolism. These drugs reduce the risk of clotting at the expense of increasing the risk of bleeding, and currently they have no specific reversal agent. However, andexanet alfa, a recombinant modified FXa decoymolecule, is in a late-phase clinical trial in bleeding patients, and ciraparantag, a small molecule that appears to reverse many anticoagulants including the FXa inhibitors, is in development. This review summarizes the published data to date on both drugs, which have the potential to change the management approach to patients with FXa inhibitoreassociated major hemorrhage.
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Affiliation(s)
- Truman J Milling
- Departments of Neurology and Surgery and Perioperative Care, Seton Dell Medical School Stroke Institute Austin, Tex
| | - Scott Kaatz
- Division of Hospital Medicine, Henry Ford Hospital, Detroit, MI.
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