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Piqueras-Sanchez C, Esteve-Pastor MA, Moreno-Fernandez J, Soler-Espejo E, Rivera-Caravaca JM, Roldán V, Marín F. Advances in the medical treatment and diagnosis of intracranial hemorrhage associated with oral anticoagulation. Expert Rev Neurother 2024; 24:913-928. [PMID: 39039686 DOI: 10.1080/14737175.2024.2379413] [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: 05/05/2024] [Accepted: 07/09/2024] [Indexed: 07/24/2024]
Abstract
INTRODUCTION With the increasing prevalence of atrial fibrillation (AF), it entails expanding oral anticoagulants (OACs) use, carrying a higher risk of associated hemorrhagic events, including intracranial hemorrhage (ICH). Despite advances in OACs development with a better safety profile and reversal agent for these anticoagulants, there is still no consensus on the optimal management of patients with OACs-associated ICH. AREAS COVERED In this review, the authors have carried out an exhaustive search on the advances in recent years. The authors provide an update on the management of ICH in anticoagulated patients, as well as an update on the latest evidence on anticoagulation resumption, recent therapeutic strategies, and investigational drugs that could play a role in the future. EXPERT OPINION Following an ICH event in an anticoagulated patient, a comprehensive clinical evaluation is imperative. Anticoagulation should be promptly withdrawn and reversed. Once the patient is stabilized, a reintroduction of anticoagulation should be considered, typically within a timeframe of 4-8 weeks, if feasible. If re-anticoagulation is not possible, alternative options such as Left Atrial Appendage Occlusion are available.
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Affiliation(s)
| | - María Asunción Esteve-Pastor
- Department of Cardiology, Hospital Clínico Universitario Virgen De La Arrixaca, Murcia, Spain
- Instituto Murciano De Investigación Biosanitaria (IMIB- Arrixaca), Murcia, Spain
- CIBERCV, Murcia, Spain
| | - Jorge Moreno-Fernandez
- Department of Cardiology, Hospital Clínico Universitario Virgen De La Arrixaca, Murcia, Spain
| | - Eva Soler-Espejo
- Instituto Murciano De Investigación Biosanitaria (IMIB- Arrixaca), Murcia, Spain
- Department of Hematology, Hospital Clínico Universitario Virgen De La Arrixaca, Murcia, Spain
| | | | - Vanessa Roldán
- Instituto Murciano De Investigación Biosanitaria (IMIB- Arrixaca), Murcia, Spain
- Department of Hematology, Hospital Clínico Universitario Virgen De La Arrixaca, Murcia, Spain
| | - Francisco Marín
- Department of Cardiology, Hospital Clínico Universitario Virgen De La Arrixaca, Murcia, Spain
- Instituto Murciano De Investigación Biosanitaria (IMIB- Arrixaca), Murcia, Spain
- CIBERCV, Murcia, Spain
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Milling TJ, Voronov A, Schmidt DS, Lindhoff-Last E. Long-Term Safety of a Four-Factor Prothrombin Complex Concentrate (Kcentra®/Beriplex® P/N): An Updated Pharmacovigilance Review. Thromb Haemost 2024. [PMID: 39074810 DOI: 10.1055/s-0044-1788305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/31/2024]
Abstract
INTRODUCTION Four-factor prothrombin complex concentrate (4F-PCC) is recommended for vitamin K antagonist reversal in patients with major bleeding or in need of surgery. The most important risk associated with the use of 4F-PCC is the occurrence of thromboembolic events (TEEs). In this review, we aim to evaluate the safety profile of a 4F-PCC (Kcentra®/Beriplex® P/N; CSL Behring, Marburg, Germany) by reviewing pharmacovigilance data. METHODS A retrospective analysis of postmarketing pharmacovigilance data of Kcentra®/Beriplex® P/N from February 1996 to April 2022 was performed and complemented by a review of clinical studies published between January 2012 and April 2022. RESULTS A total of 2,321,443 standard infusions of Kcentra®/Beriplex® P/N were administered during the evaluation period. Adverse drug reactions (ADRs) were reported in 614 cases (∼1 per 3,781 standard infusions) and 233 of these cases (37.9%) experienced suspected TEEs related to 4F-PCC (∼1 per 9,963 standard infusions); most of these cases had pre-existing or concomitant conditions likely to be significant risk factors for thrombosis. TEE rates were similar when 4F-PCC was used on-label or off-label for direct oral anticoagulant-associated bleeding. Thirty-six cases (5.9%) reported hypersensitivity type reactions (∼1 per 64,485 standard infusions). No confirmed case of viral transmission related to 4F-PCC use was reported. The published literature also revealed a favorable safety profile of 4F-PCC. CONCLUSION Analysis of postmarketing pharmacovigilance safety reports demonstrated that treatment with 4F-PCC was associated with few ADRs and a low rate of TEEs across multiple indications and settings, thus confirming a positive safety profile of 4F-PCC.
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Affiliation(s)
- Truman J Milling
- Department of Clinical Sciences, Tilman J. Fertitta Family College of Medicine, University of Houston, Houston, Texas, United States
| | - Anna Voronov
- CSL Behring Australia Pty Ltd, Melbourne, Victoria, Australia
| | | | - Edelgard Lindhoff-Last
- Cardiology Angiology Center Bethanien, CCB Coagulation Research Center, Frankfurt, Germany
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Desvages M, Borgel D, Adam F, Tu G, Jaouen S, Reperant C, Denis CV, Desmaële D, Bianchini EP. A small-molecule hemostatic agent for the reversal of direct oral anticoagulant-induced bleeding. Res Pract Thromb Haemost 2024; 8:102426. [PMID: 38882463 PMCID: PMC11179090 DOI: 10.1016/j.rpth.2024.102426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 04/16/2024] [Accepted: 04/17/2024] [Indexed: 06/18/2024] Open
Abstract
Background The bleeding risk associated with direct oral anticoagulants (DOACs) remains a major concern, and rapid reversal of anticoagulant activity may be required. Although specific and nonspecific hemostatic biotherapies are available, there is a need for small-molecule DOAC reversal agents that are simple and cost-effective to produce, store, and administer. Objectives To identify and characterize a small molecule with procoagulant activity as a DOAC reversal agent. Methods We sought to identify a small procoagulant molecule by screening a chemical library with a plasma clotting assay. The selected molecule was assessed for its procoagulant properties and its ability to reverse the effects of the DOACs in a thrombin generation assay. Its activity as a DOAC reversal agent was also evaluated in a tail-clip bleeding assay in mice. Results The hemostatic molecule (HeMo) dose-dependently promoted thrombin generation in plasma, with dose values effective in producing half-maximum response ranging between 3 and 5 μM, depending on the thrombin generation assay parameter considered. HeMo also restored impaired thrombin generation in DOAC-spiked plasma and reversed DOAC activity in the mouse bleeding model. HeMo significantly reduced apixaban-induced bleeding from 709 to 65 μL (vs 43 μL in controls; P < .01) and dabigatran-induced bleeding from 989 to 155 μL (vs 126 μL in controls; P < .01). Conclusion HeMo is a small-molecule procoagulant that can counterbalance hemostatic disruption by a thrombin inhibitor (dabigatran) or factor Xa inhibitors (apixaban and rivaroxaban). The compound's effective clot formation and versatility make it a possible option for managing the inherent hemorrhagic risk during DOAC therapy.
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Affiliation(s)
- Maximilien Desvages
- Université Paris-Saclay, Institut National de la Santé et de la Recherche Médicale, Unité Mixte de Recherche 1176, Le Kremlin-Bicêtre, France
- Service d'Hématologie Biologique, Hôpital Necker Enfants Malades, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Delphine Borgel
- Université Paris-Saclay, Institut National de la Santé et de la Recherche Médicale, Unité Mixte de Recherche 1176, Le Kremlin-Bicêtre, France
- Service d'Hématologie Biologique, Hôpital Necker Enfants Malades, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Frédéric Adam
- Université Paris-Saclay, Institut National de la Santé et de la Recherche Médicale, Unité Mixte de Recherche 1176, Le Kremlin-Bicêtre, France
| | - Ge Tu
- Université Paris-Saclay, Institut National de la Santé et de la Recherche Médicale, Unité Mixte de Recherche 1176, Le Kremlin-Bicêtre, France
- Université Paris-Saclay, Centre National de la Recherche Scientifique, Unité Mixte de Recherche 8612, Institut Galien Paris-Saclay, Orsay, France
| | - Simon Jaouen
- Université Paris-Saclay, Institut National de la Santé et de la Recherche Médicale, Unité Mixte de Recherche 1176, Le Kremlin-Bicêtre, France
| | - Christelle Reperant
- Université Paris-Saclay, Institut National de la Santé et de la Recherche Médicale, Unité Mixte de Recherche 1176, Le Kremlin-Bicêtre, France
| | - Cécile V Denis
- Université Paris-Saclay, Institut National de la Santé et de la Recherche Médicale, Unité Mixte de Recherche 1176, Le Kremlin-Bicêtre, France
| | - Didier Desmaële
- Université Paris-Saclay, Centre National de la Recherche Scientifique, Unité Mixte de Recherche 8612, Institut Galien Paris-Saclay, Orsay, France
| | - Elsa P Bianchini
- Université Paris-Saclay, Institut National de la Santé et de la Recherche Médicale, Unité Mixte de Recherche 1176, Le Kremlin-Bicêtre, France
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Sarode R, Welsby IJ, Hoffman M. Clinical Relevance of Preclinical and Clinical Studies of Four-Factor Prothrombin Complex Concentrate for Treatment of Bleeding Related to Direct Oral Anticoagulants. Ann Emerg Med 2023; 82:341-361. [PMID: 37204347 DOI: 10.1016/j.annemergmed.2023.04.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 04/06/2023] [Accepted: 04/13/2023] [Indexed: 05/20/2023]
Abstract
Direct oral anticoagulants (DOACs) are widely used for the prevention and treatment of venous thromboembolism and stroke. When emergency reversal of DOAC-related anticoagulation is required, specific DOAC reversal agents are recommended, including idarucizumab for dabigatran reversal and andexanet alfa for apixaban and rivaroxaban reversal. However, specific reversal agents are not always available, andexanet alfa has not been approved for urgent surgery, and clinicians need to know the patient's anticoagulant medication before administering these treatments. Four-factor prothrombin complex concentrates (4F-PCCs) are recognized as nonspecific, alternative hemostatic agents for treatment of DOAC-related bleeding. Evidence from preclinical and clinical studies shows that they may reduce the anticoagulant effects of DOACs and may help control DOAC-related bleeding. However, randomized controlled trials are lacking, and most data are from retrospective or single-arm prospective studies in bleeding associated with activated factor X inhibitors. There are no clinical data showing the efficacy of 4F-PCC for the treatment of bleeding in dabigatran-treated patients. This review focuses on the current evidence of 4F-PCC use in controlling bleeding associated with DOACs and provides an expert opinion on the relevance of these data for clinical practice. The current treatment landscape, unmet needs, and future directions are also discussed.
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Affiliation(s)
- Ravi Sarode
- Department of Pathology and Internal Medicine (Hematology/Oncology), UT Southwestern Medical Center, Dallas, TX.
| | - Ian J Welsby
- Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Maureane Hoffman
- Department of Pathology, Duke University School of Medicine, Durham, NC
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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: 0] [Impact Index Per Article: 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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6
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Ripoll JG, Klompas AM, Smith BB, Smith MM. Contemporary Perioperative Management of Direct Oral Anticoagulants. Adv Anesth 2022; 40:93-109. [PMID: 36333054 DOI: 10.1016/j.aan.2022.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Direct oral anticoagulants (DOACs) have rapidly emerged as popular alternatives to warfarin in the setting of nonvalvular atrial fibrillation, prevention and treatment of venous thromboembolism, and secondary prevention of arterial thrombosis. It is now estimated that more patients in the United States take DOACs than warfarin for approved indications. Studies to date have shown that these drugs are similarly efficacious with perhaps a lower bleeding risk than warfarin. The purpose of this review is to provide insight into the currently available DOACs and discuss the management and reversal strategies for patients in the perioperative period.
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Affiliation(s)
- Juan G Ripoll
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Allan M Klompas
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Bradford B Smith
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA
| | - Mark M Smith
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine, 200 First Street Southwest, Rochester, MN 55905, USA.
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7
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Chaudhary R, Singh A, Chaudhary R, Bashline M, Houghton DE, Rabinstein A, Adamski J, Arndt R, Ou NN, Rudis MI, Brown CS, Wieruszewski ED, Wanek M, Brinkman NJ, Linderbaum JA, Sorenson MA, Atkinson JL, Thompson KM, Aiyer AN, McBane RD. Evaluation of Direct Oral Anticoagulant Reversal Agents in Intracranial Hemorrhage: A Systematic Review and Meta-analysis. JAMA Netw Open 2022; 5:e2240145. [PMID: 36331504 PMCID: PMC9636520 DOI: 10.1001/jamanetworkopen.2022.40145] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
IMPORTANCE Direct oral anticoagulant (DOAC)-associated intracranial hemorrhage (ICH) has high morbidity and mortality. The safety and outcome data of DOAC reversal agents in ICH are limited. OBJECTIVE To evaluate the safety and outcomes of DOAC reversal agents among patients with ICH. DATA SOURCES PubMed, MEDLINE, The Cochrane Library, Embase, EBSCO, Web of Science, and CINAHL databases were searched from inception through April 29, 2022. STUDY SELECTION The eligibility criteria were (1) adult patients (age ≥18 years) with ICH receiving treatment with a DOAC, (2) reversal of DOAC, and (3) reported safety and anticoagulation reversal outcomes. All nonhuman studies and case reports, studies evaluating patients with ischemic stroke requiring anticoagulation reversal or different dosing regimens of DOAC reversal agents, and mixed study groups with DOAC and warfarin were excluded. DATA EXTRACTION AND SYNTHESIS Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines were used for abstracting data and assessing data quality and validity. Two reviewers independently selected the studies and abstracted data. Data were pooled using the random-effects model. MAIN OUTCOMES AND MEASURES The primary outcome was proportion with anticoagulation reversed. The primary safety end points were all-cause mortality and thromboembolic events after the reversal agent. RESULTS A total of 36 studies met criteria for inclusion, with a total of 1832 patients (967 receiving 4-factor prothrombin complex concentrate [4F-PCC]; 525, andexanet alfa [AA]; 340, idarucizumab). The mean age was 76 (range, 68-83) years, and 57% were men. For 4F-PCC, anticoagulation reversal was 77% (95% CI, 72%-82%; I2 = 55%); all-cause mortality, 26% (95% CI, 20%-32%; I2 = 68%), and thromboembolic events, 8% (95% CI, 5%-12%; I2 = 41%). For AA, anticoagulation reversal was 75% (95% CI, 67%-81%; I2 = 48%); all-cause mortality, 24% (95% CI, 16%-34%; I2 = 73%), and thromboembolic events, 14% (95% CI, 10%-19%; I2 = 16%). Idarucizumab for reversal of dabigatran had an anticoagulation reversal rate of 82% (95% CI, 55%-95%; I2 = 41%), all-cause mortality, 11% (95% CI, 8%-15%, I2 = 0%), and thromboembolic events, 5% (95% CI, 3%-8%; I2 = 0%). A direct retrospective comparison of 4F-PCC and AA showed no differences in anticoagulation reversal, proportional mortality, or thromboembolic events. CONCLUSIONS AND RELEVANCE In the absence of randomized clinical comparison trials, the overall anticoagulation reversal, mortality, and thromboembolic event rates in this systematic review and meta-analysis appeared similar among available DOAC reversal agents for managing ICH. Cost, institutional formulary status, and availability may restrict reversal agent choice, particularly in small community hospitals.
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Affiliation(s)
- Rahul Chaudhary
- Division of Cardiology, Department of Medicine, University of Pittsburgh Heart and Vascular Institute, Pittsburgh, Pennsylvania
| | - Amteshwar Singh
- Division of Hospital Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Michael Bashline
- Division of Cardiology, Department of Medicine, University of Pittsburgh Heart and Vascular Institute, Pittsburgh, Pennsylvania
| | - Damon E. Houghton
- Division of Vascular Medicine, Department of Cardiovascular Diseases, Mayo Clinic Rochester, Minnesota
- Division of Hematology/Oncology, Department of Internal Medicine, Mayo Clinic Rochester, Minnesota
| | | | - Jill Adamski
- Department of Laboratory Medicine and Pathology, Mayo Clinic Hospital, Phoenix, Arizona
| | - Richard Arndt
- Department of Pharmacy, Mayo Clinic Health System, Eau Claire, Wisconsin
| | - Narith N. Ou
- Department of Pharmacy, Mayo Clinic, Rochester, Minnesota
| | - Maria I. Rudis
- Departments of Pharmacy and Emergency Medicine, Mayo Clinic, Rochester, Minnesota
| | - Caitlin S. Brown
- Departments of Pharmacy and Emergency Medicine, Mayo Clinic, Rochester, Minnesota
| | - Erin D. Wieruszewski
- Departments of Pharmacy and Emergency Medicine, Mayo Clinic, Rochester, Minnesota
| | - Matthew Wanek
- Department of Pharmacy, Mayo Clinic, Phoenix, Arizona
| | | | - Jane A. Linderbaum
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | | | | | | | - Aryan N. Aiyer
- Division of Cardiology, Department of Medicine, University of Pittsburgh Heart and Vascular Institute, Pittsburgh, Pennsylvania
| | - Robert D. McBane
- Division of Vascular Medicine, Department of Cardiovascular Diseases, Mayo Clinic Rochester, Minnesota
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Hofer S, Schlimp CJ, Casu S, Grouzi E. Management of Coagulopathy in Bleeding Patients. J Clin Med 2021; 11:jcm11010001. [PMID: 35011742 PMCID: PMC8745606 DOI: 10.3390/jcm11010001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 12/10/2021] [Accepted: 12/14/2021] [Indexed: 02/06/2023] Open
Abstract
Early recognition of coagulopathy is necessary for its prompt correction and successful management. Novel approaches, such as point-of-care testing (POC) and administration of coagulation factor concentrates (CFCs), aim to tailor the haemostatic therapy to each patient and thus reduce the risks of over- or under-transfusion. CFCs are an effective alternative to ratio-based transfusion therapies for the correction of different types of coagulopathies. In case of major bleeding or urgent surgery in patients treated with vitamin K antagonist anticoagulants, prothrombin complex concentrate (PCC) can effectively reverse the effects of the anticoagulant drug. Evidence for PCC effectiveness in the treatment of direct oral anticoagulants-associated bleeding is also increasing and PCC is recommended in guidelines as an alternative to specific reversal agents. In trauma-induced coagulopathy, fibrinogen concentrate is the preferred first-line treatment for hypofibrinogenaemia. Goal-directed coagulation management algorithms based on POC results provide guidance on how to adjust the treatment to the needs of the patient. When POC is not available, concentrate-based management can be guided by other parameters, such as blood gas analysis, thus providing an important alternative. Overall, tailored haemostatic therapies offer a more targeted approach to increase the concentration of coagulation factors in bleeding patients than traditional transfusion protocols.
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Affiliation(s)
- Stefan Hofer
- Department of Anaesthesiology, Westpfalz-Klinikum Kaiserslautern, 67655 Kaiserlautern, Germany
- Correspondence: ; Tel.: +49-631-203-1030
| | - Christoph J. Schlimp
- Department of Anaesthesiology and Intensive Care, AUVA Trauma Hospital Linz, 4010 Linz, Austria;
- Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, AUVA Research Center, 1200 Vienna, Austria
| | - Sebastian Casu
- Emergency Department, Asklepios Hospital Wandsbek, 22043 Hamburg, Germany;
| | - Elisavet Grouzi
- Transfusion Service and Clinical Hemostasis, Saint Savvas Oncology Hospital, 115 22 Athens, Greece;
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Braun G. [Management of bleeding in patients on antithrombotic therapy]. Med Klin Intensivmed Notfmed 2021; 116:491-498. [PMID: 34463792 DOI: 10.1007/s00063-021-00848-7] [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: 05/03/2021] [Revised: 06/24/2021] [Accepted: 07/12/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Severe bleeding under antithrombotic therapy is common and challenging in intensive care medicine; on the one hand, rapid bleeding control must be achieved and, on the other hand, thromboembolic complications must be avoided. AIMS The paper will provide a brief overview of direct oral anticoagulants, therapeutic options and precise instructions for dealing with severe bleeding. RESULTS In addition to general measures in direct oral anticoagulant (DOAC)-associated major bleeding, prothrombin complex concentrate (PCC), idarucizumab and andexanet alfa are available as specific antidote therapy. In case of bleeding under heparin therapy, protamine sulfate is available as a possible antidote. CONCLUSIONS In particular, the importance of andexanet alfa in the treatment of factor Xa inhibitor-associated bleeding requires further investigation.
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Affiliation(s)
- Georg Braun
- Intensivzentrum, Medizinische Klinik 3 am Universitätsklinikum Augsburg, Stenglinstr. 2, 86156, Augsburg, Deutschland.
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10
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Dev P, Abousaab C, Zhou C, Sarode R. Efficacy of prothrombin complex concentrate in the management of oral factor Xa inhibitors associated major bleed assessed by ISTH and ANNEXA-4 criteria. J Thromb Thrombolysis 2021; 53:249-256. [PMID: 34373984 DOI: 10.1007/s11239-021-02536-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/17/2021] [Indexed: 11/29/2022]
Abstract
Direct oral anticoagulants (DOACs) are increasingly used for stroke prevention in atrial fibrillation and treatment and prevention of venous thromboembolism. They are also associated with bleeding risk. Existing literature suggests that prothrombin complex concentrate (PCC) administration may help control bleeding due to factor Xa inhibitors (FXaI). To determine the hemostatic efficacy of PCC in patients with major bleeding due to FXaI, we performed a retrospective chart review of 50 patients who presented with FXaI associated major bleeding that required urgent hemostatic management. Hemostatic assessment was performed using ISTH and ANNEXA-4 criteria. Twenty patients presented with intracranial hemorrhage (ICH), 20 had gastrointestinal bleeding, 3 had visceral bleeding, 3 had genitourinary bleeding, and 4 had miscellaneous types of bleeding. Fifty-six percent (28/50) had effective hemostasis using ISTH criteria and 84% (42/50) achieved effective hemostasis by ANNEXA-4 criteria. Hemostatic efficacy was similar by both tools for ICH (75% each). However, there was a major difference between ISTH and ANNEXA-4 hemostatic efficacy assessments for GI bleeding (45% and 95%, respectively). When comparing rivaroxaban and apixaban, there was no significant difference in effective hemostasis using either criteria, time to hemostasis, thromboembolic events, or patient mortality. Five (10%) patients had thromboembolic events within seven days of PCC administration, and the 30-day mortality rate was 14% (7/50). Our study shows similar efficacy, thromboembolic events, and mortality associated with PCC compared to andexanet alfa using ANNEXA-4 criteria, suggesting that PCC may be a viable alternative.
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Affiliation(s)
- Pallavi Dev
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA.
| | - Carol Abousaab
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA
| | - Cecilia Zhou
- UT Southwestern Medical School, UT Southwestern Medical Center, Dallas, TX, USA
| | - Ravi Sarode
- Department of Pathology and Internal Medicine (Hematology/Oncology), UT Southwestern Medical Center, Dallas, TX, USA
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11
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Meta-Analysis of Reversal Agents for Severe Bleeding Associated With Direct Oral Anticoagulants. J Am Coll Cardiol 2021; 77:2987-3001. [PMID: 34140101 DOI: 10.1016/j.jacc.2021.04.061] [Citation(s) in RCA: 59] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 03/30/2021] [Accepted: 04/13/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Direct oral anticoagulants (DOACs) have shown a positive benefit-risk balance in both clinical trials and real-world data, but approximately 2% to 3.5% of patients experience major bleeding annually. Many of these patients require hospitalization, and the administration of reversal agents may be required to control bleeding. OBJECTIVES The aim of this study was to investigate clinical outcomes associated with the use of 4-factor prothrombin complex concentrates, idarucizumab, or andexanet for reversal of severe DOAC-associated bleeding. METHODS The investigators systematically searched for studies of reversal agents for the treatment of severe bleeding associated with DOAC. Mortality rates, thromboembolic events, and hemostatic efficacy were meta-analyzed using a random effects model. RESULTS The investigators evaluated 60 studies in 4,735 patients with severe DOAC-related bleeding who were treated with 4-factor prothrombin complex concentrates (n = 2,688), idarucizumab (n = 1,111), or andexanet (n = 936). The mortality rate was 17.7% (95% confidence interval [CI]: 15.1% to 20.4%), and it was higher in patients with intracranial bleedings (20.2%) than in patients with extracranial hemorrhages (15.4%). The thromboembolism rate was 4.6% (95% CI: 3.3% to 6.0%), being particularly high with andexanet (10.7%; 95% CI: 6.5% to 15.7%). The effective hemostasis rate was 78.5% (95% CI: 75.1% to 81.8%) and was similar regardless of the reversal agent considered. The rebleeding rate was 13.2% (95% CI: 5.5% to 23.1%) and 78% of rebleeds occurred after resumption of anticoagulation. The risk of death was markedly and significantly associated with failure to achieve effective hemostasis (relative risk: 3.63; 95% CI: 2.56 to 5.16). The results were robust regardless of the type of study or the hemostatic scale used. CONCLUSIONS The risk of death after severe DOAC-related bleeding remains significant despite a high rate of effective hemostasis with reversal agents. Failure to achieve effective hemostasis strongly correlated with a fatal outcome. Thromboembolism rates are particularly high with andexanet. Comparative clinical trials are needed.
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Ibarra F. Review of Prothrombin Complex Concentrates Use in Apixaban and Rivaroxaban Associated Intracranial Hemorrhages. J Pharm Pract 2021; 35:1012-1020. [PMID: 34036837 DOI: 10.1177/08971900211015059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
STUDY OBJECTIVE Summarize the studies evaluating the use of 4-factor prothrombin complex concentrates in the management of apixaban and rivaroxaban associated intracranial hemorrhages. METHODS A PubMed literature search was conducted for articles published between 2013 and 2020 which contained the following terms in their title: (1) apixaban, rivaroxaban, or factor Xa inhibitor*, and (2) prothrombin complex concentrate*. RESULTS Eighteen observational studies were included. When a ∼25 units/kg (range: 25-26.9 units/kg) non-activated 4 factor prothrombin complex concentrate dose was administered, the hemostatic effectiveness rates were ≥ 79% in 2/4 studies that utilized the Sarode et al criteria, in comparison to 4/5 studies that administered a 50 units/kg dose. The mortality rates were < 20% in 7/9 studies with hemostatic effectiveness rates ≥ 79%. Mortality rates were lower in the studies demonstrating higher hemostatic effectiveness rates and including patients with higher Glasgow coma scale scores and lower intracerebral hemorrhage volumes. Overall, the thromboembolic event rates were 0-18%, with 16/18 studies demonstrating rates ≤ 10%. The thromboembolic event rates were not dose or agent dependent. CONCLUSION Rates of hemostatic effectiveness were influenced by the definition of hemostatic effectiveness, dose administered, and patient severity. Studies suggest that higher doses may result in higher hemostatic effectiveness rates without increasing the risk of experiencing a thromboembolic event. This review may be used by providers to modify or validate their reversal strategy approach until well designed studies are available.
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