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Shaw JR, Almujalli AA, Xu Y, Levy JH, Schulman S, Siegal D, Dowlatshahi D, Tokessy M, Buyukdere H, Carrier M, Castellucci LA. Prothrombin complex concentrate for direct factor Xa inhibitor-associated bleeding or before urgent surgery. Thromb Res 2024; 243:109172. [PMID: 39362177 DOI: 10.1016/j.thromres.2024.109172] [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: 06/17/2024] [Revised: 09/20/2024] [Accepted: 09/23/2024] [Indexed: 10/05/2024]
Abstract
INTRODUCTION Factor Xa inhibitor (FXaI)-associated bleeding events are common and associated with substantial morbidity. Systematic evaluation of widely available, effective, and affordable FXaI bleed management strategies is needed. MATERIALS AND METHODS We conducted a single-center retrospective cohort study of FXaI-treated patients presenting to a tertiary academic medical center from January 2018 to May 2019 who received 25-50 IU/kg 4F-PCC for either FXaI-associated major bleeding or urgent surgery. The primary outcome was hemostatic efficacy, and the safety outcome was the 30-day risk of thromboembolism. RESULTS PCC was used to treat FXaI-associated bleeding in 83 cases (79.1 %) and was given before urgent surgery in 22 cases (20.9 %). Sixty-six patients were on apixaban, 38 were on rivaroxaban and one patient was on edoxaban. Intracranial hemorrhage (ICH) and gastrointestinal bleeding accounted for most bleeds (74.7 %). Median interval between last DOAC intake and presentation to triage was 9 h [IQR 5.3-14.8] and median PCC dosing was 40.0 IU/kg [IQR 28.5-46.6]. Forty-two patients (40.0 %) had pre-PCC FXaI levels drawn with median FXaI levels of 114.5 ng/mL [IQR 70.0-175.0]. Effective hemostasis occurred in 66.7 % [95%CI 55.4-76.3] of patients receiving PCC for bleeding and surgical hemostasis was rated as normal in 95.5 % (95%CI 76.5-100.0) for patients having urgent surgery. The 30-day risk of thromboembolism was 7.6 % [95%CI 3.7-14.5] and 22.9 % [95%CI 15.8-31.8] of patients died. CONCLUSIONS PCC for FXaI-associated bleeding was associated with hemostatic efficacy in two-thirds of patients and thromboembolic events were uncommon. PCC represents a promising treatment strategy for FXaI-associated bleeding.
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Affiliation(s)
- Joseph R Shaw
- Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, ON, Canada.
| | | | - Yan Xu
- Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Jerrold H Levy
- Department of Anesthesiology, Critical Care, and Surgery, Duke University School of Medicine, Durham, NC, USA
| | - Sam Schulman
- Department of Medicine, McMaster University, Hamilton, ON, Canada; Department of Obstetrics and Gynecology and Perinatal Medicine, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Deborah Siegal
- Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Dar Dowlatshahi
- Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Melanie Tokessy
- Department of Pathology and Laboratory Medicine, Division of Hematology and Transfusion Medicine, The Ottawa Hospital, Ottawa, ON, Canada
| | - Hakan Buyukdere
- Department of Pathology and Laboratory Medicine, Division of Hematology and Transfusion Medicine, The Ottawa Hospital, Ottawa, ON, Canada
| | - Marc Carrier
- Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Lana A Castellucci
- Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, ON, Canada
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Chabata CV, Yu H, Ke L, Frederiksen JW, Patel PA, Sullenger BA, Thalji NK. Andexanet alfa-associated heparin resistance in cardiac surgery: mechanism and in vitro perspectives. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2024.09.09.612152. [PMID: 39314402 PMCID: PMC11419022 DOI: 10.1101/2024.09.09.612152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/25/2024]
Abstract
Background Andexanet alfa (andexanet) is the only FDA-approved antidote for direct factor Xa (FXa) inhibitors but has been reported to cause resistance to unfractionated heparin (UFH). This has delayed anticoagulation for procedures requiring cardiopulmonary bypass (CPB). The mechanism, andexanet and UFH dose dependence, and thrombotic risk of andexanet-associated heparin resistance are unknown. Methods The effect of andexanet in vitro was determined using activated clotting times (ACT) and thromboelastography (TEG). Ex vivo CPB circuits were used to determine whether andexanet impaired anticoagulation for extracorporeal circulation. Kinetics of antithrombin (AT) inhibition of FXa and thrombin were measured in the presence of andexanet. Equilibrium modeling and thrombin generation assay (TGA) validation were used to predict the role of andexanet, AT, and UFH concentrations in andexanet-associated heparin resistance. Results Andexanet prevented UFH-mediated prolongation of ACT and TEG times. At lower concentrations of andexanet, heparin resistance could be overcome with suprapharmacologic doses of UFH, but not at higher andexanet concentrations. Andexanet rendered standard doses of UFH inadequate to prevent circuit thrombosis, and suprapharmacologic UFH doses were only partially able to overcome this. Scanning electron microscopy demonstrated coagulation activation in circuits. Andexanet prevented UFH enhancement of AT-mediated inhibition of FXa and thrombin. Equilibrium modeling and TGA validation demonstrated that andexanet creates a triphasic equilibrium with UFH and AT: initial UFH unresponsiveness, normal UFH responsiveness when andexanet is depleted, and finally AT depletion. Sufficient CPB heparinization can only occur at low therapeutic andexanet doses and normal AT levels. Higher andexanet doses or AT deficiency may require both AT supplementation and very high UFH doses. Conclusions Andexanet causes heparin resistance due to redistribution of UFH-bound AT. If andexanet cannot be avoided prior to heparinization and direct thrombin inhibitors are undesirable, our in vitro study suggests excess UFH should be considered as a potential strategy prior to AT supplementation. Highlights Andexanet alfa causes heparin resistance not by depleting antithrombin, but rather by sequestering heparin-bound antithrombin such that it cannot act as an anticoagulant.Heparin responsiveness in the presence of Andexanet alfa is triphasic such that the effect of a dose of heparin can now be predicted in vitro based on the relative concentrations of andexanet, heparin, and antithrombin.The in vitro insights provided by this work provide a rational starting point for further clinical elucidation of the problem and management of andexanet-associated heparin resistance.
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Shaw JR, Unachukwu U, Cyr J, Siegal DM, Castellucci LA, Dreden PV, Dowlatshahi D, Buyukdere H, Ramsay T, Carrier M. Effect of PCC on Thrombin Generation among Patients on Factor Xa Inhibitors with Major Bleeding or Needing Urgent Surgery (GAUGE): Design and Rationale. TH OPEN 2023; 7:e229-e240. [PMID: 37497426 PMCID: PMC10368490 DOI: 10.1055/s-0043-1771300] [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: 03/21/2023] [Accepted: 06/12/2023] [Indexed: 07/28/2023] Open
Abstract
Background Direct factor Xa inhibitors (FXaIs) account for most oral anticoagulant use and FXaI-associated bleeding events are common. Clinicians have variable national and regional access to specific FXaI reversal agents such as andexanet alfa. Many centers have adopted the use of prothrombin complex concentrates (PCCs) as hemostatic therapy for FXaI-associated major bleeding events. PCC does not impact circulating FXaI levels and its mechanism of action to achieve hemostasis in FXaI-associated bleeding is uncertain. While PCC increases quantitative thrombin generation assay (TGA) parameters, it does not correct FXaI-altered thrombin generation kinetics, nor does it normalize thrombin generation. Clinical data supporting the use of PCC are based on cohort studies reporting clinical hemostatic efficacy, which is difficult to measure. The benefits of PCC for FXaI-associated bleeding beyond supportive care are uncertain. Objective GAUGE is a prospective observational study designed to measure the effects of four-factor PCC administration (Octaplex) on TGA parameters among patients with FXaI-associated bleeding or needing urgent surgery. Methods Laboratory outcomes will include the mean paired change in TGA parameters from pre- to post-PCC administration and the proportion of participants whose post-PCC TGA values fall within a defined reference range. Clinical outcomes will include hemostatic efficacy, thromboembolic complications, and all-cause death at 30 days post-PCC. Conclusion Development of a viable and universally accessible FXaI bleed management strategy is crucial. GAUGE will provide in vivo data on the effects of PCC among patients with FXaI-associated bleeding.
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Affiliation(s)
- Joseph R. Shaw
- Department of Medicine, Division of Hematology, University of Ottawa, Ottawa, Canada
- Ottawa Hospital Research Institute, Ottawa, Canada
| | - Ubabuko Unachukwu
- Department of Medicine, Division of Hematology, University of Ottawa, Ottawa, Canada
- Ottawa Hospital Research Institute, Ottawa, Canada
| | - Joseph Cyr
- Department of Medicine, Division of Hematology, University of Ottawa, Ottawa, Canada
- Ottawa Hospital Research Institute, Ottawa, Canada
| | - Deborah M. Siegal
- Department of Medicine, Division of Hematology, University of Ottawa, Ottawa, Canada
- Ottawa Hospital Research Institute, Ottawa, Canada
| | - Lana A. Castellucci
- Department of Medicine, Division of Hematology, University of Ottawa, Ottawa, Canada
- Ottawa Hospital Research Institute, Ottawa, Canada
| | | | - Dar Dowlatshahi
- Department of Medicine, Division of Hematology, University of Ottawa, Ottawa, Canada
- Ottawa Hospital Research Institute, Ottawa, Canada
- Brain and Mind Research Institute, Ottawa, Canada
| | - Hakan Buyukdere
- Department of Pathology and Laboratory Medicine, University of Ottawa, Ottawa, Canada
| | | | - Marc Carrier
- Department of Medicine, Division of Hematology, University of Ottawa, Ottawa, Canada
- Ottawa Hospital Research Institute, Ottawa, Canada
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Frol S, Oblak JP, Šabovič M, Kermer P. Andexanet Alfa to Reverse the Effect of Factor Xa Inhibitors in Intracranial Hemorrhage. CNS Drugs 2023; 37:477-487. [PMID: 37133623 DOI: 10.1007/s40263-023-01006-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/16/2023] [Indexed: 05/04/2023]
Abstract
Andexanet alfa (AA) is a recombinant factor Xa competing for binding with factor Xa inhibitors, thereby reversing their anticoagulation effects. Since 2019, it has been approved for individuals under apixaban or rivaroxaban therapy suffering from life-threatening or uncontrolled bleeding. Apart from the pivotal trial, real-world data on the use of AA in daily clinics are scarce. We reviewed the current literature on patients with intracranial hemorrhage (ICH) and summarized the available evidence regarding several outcome parameters. On the basis of this evidence, we provide a standard operating procedure (SOP) for routine AA application. We searched PubMed and additional databases through 18 January 2023 for case reports, case series, studies, reviews, and guidelines. Data on hemostatic efficacy, in-hospital mortality, and thrombotic events were pooled and compared with the pivotal trial data. While hemostatic efficacy in world-wide clinical routine seems to be comparable to the pivotal trial, thrombotic events and in-hospital mortality appear to be substantially higher. Various confounding factors responsible for this finding such as exclusion and inclusion criteria resulting in a highly selected patient cohort within the controlled clinical trial have to be considered. The SOP provided should support physicians in patient selection for AA treatment as well as facilitate routine use and dosing. This review underlines the urgent need for more data from randomized trials to appreciate the benefit and safety profile of AA. Meanwhile, this SOP should help to improve frequency and quality of AA use in patients suffering from ICH while on apixaban or rivaroxaban treatment.
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Affiliation(s)
- Senta Frol
- Department of Vascular Neurology, University Medical Center Ljubljana, Zaloška 2, 1000, Ljubljana, Slovenia.
- Faculty of Medicine, University of Ljubljana, Zaloška 2, 1000, Ljubljana, Slovenia.
| | - Janja Pretnar Oblak
- Department of Vascular Neurology, University Medical Center Ljubljana, Zaloška 2, 1000, 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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Shaw JR, Castellucci LA, Siegal D, Carrier M. DOAC-associated bleeding, hemostatic strategies, and thrombin generation assays - a review of the literature. J Thromb Haemost 2023; 21:433-452. [PMID: 36696204 DOI: 10.1016/j.jtha.2022.11.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 10/24/2022] [Accepted: 11/15/2022] [Indexed: 01/26/2023]
Abstract
Direct oral anticoagulants (DOACs) account for most oral anticoagulant use. DOAC-associated bleeding events are commonly encountered in clinical practice and are associated with substantial morbidity and mortality. Both specific reversal agents and nonspecific hemostatic therapies, such as prothrombin complex concentrates, are used in the management of DOAC-associated bleeding. Measuring hemostatic efficacy and demonstrating a clinical impact from these therapies among studies of bleeding patients is challenging. Thrombin generation assays provide information on the total hemostatic potential of plasma, and have emerged as a promising modality to both measure the impact of DOACs on coagulation and to evaluate the effects of hemostatic therapies among patients with DOAC-associated bleeding. The mechanisms by which nonspecific hemostatic agents impact coagulation and thrombin generation in the context of DOAC therapy are unclear. As a result, we undertook a review of the literature using a systematic search strategy with the goal of summarizing the effects of DOACs on thrombin generation and the effects of both specific reversal agents and nonspecific hemostatic therapies on DOAC-altered thrombin generation parameters. We sought to identify clinical studies focusing on whether altered thrombin generation is associated with clinical bleeding and whether correction of altered thrombin generation parameters predicts improvements in clinical hemostasis. Lastly, we sought to outline future directions for the application of thrombin generation assays toward anticoagulation therapies and the question of anticoagulation reversal.
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Affiliation(s)
- Joseph R Shaw
- Department of Medicine, University of Ottawa and the Ottawa Hospital Research Institute, Ottawa, Canada.
| | - Lana A Castellucci
- Department of Medicine, University of Ottawa and the Ottawa Hospital Research Institute, Ottawa, Canada
| | - Deborah Siegal
- Department of Medicine, University of Ottawa and the Ottawa Hospital Research Institute, Ottawa, Canada
| | - Marc Carrier
- Department of Medicine, University of Ottawa and the Ottawa Hospital Research Institute, Ottawa, Canada
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Abdulrehman J, Eikelboom JW, Siegal DM. Andexanet alfa for reversal of factor Xa inhibitors: a critical review of the evidence. Future Cardiol 2019; 15:395-404. [DOI: 10.2217/fca-2019-0038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Direct oral anticoagulants are associated with lower rates of bleeding than vitamin K antagonists, but life-threatening bleeding still occurs. Andexanet alfa is a catalytically inactive recombinant modified human factor Xa molecule that reverses the anticoagulant effect of direct and indirect acting factor Xa inhibitors. In the ANNEXA-4 study, treatment with andexanet was associated with a 92% reduction in median anti-Xa activity levels and excellent or good hemostasis in 82% of patients presenting with serious bleeding while receiving apixaban or rivaroxaban. In this review, we discuss the burden of bleeding in anticoagulated patients and the need for reversal agents, review the mechanism of action of andexanet and critically evaluate the evidence for its efficacy and safety.
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Affiliation(s)
- Jameel Abdulrehman
- Division of Hematology, Department of Medicine, University Health Network, Toronto, ON, M5G 2C4, Canada
| | - John W Eikelboom
- Division of Hematology & Thromboembolism, Department of Medicine, McMaster University, Hamilton, ON, L8S 4L8, Canada
- Population Health Research Institute, Hamilton Health Sciences Corporation & McMaster University, Hamilton, ON, L8L 2X2, Canada
| | - Deborah M Siegal
- Division of Hematology & Thromboembolism, Department of Medicine, McMaster University, Hamilton, ON, L8S 4L8, Canada
- Population Health Research Institute, Hamilton Health Sciences Corporation & McMaster University, Hamilton, ON, L8L 2X2, Canada
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Favresse J, Hardy M, van Dievoet MA, Sennesael AL, Douxfils J, Samama CM, Vornicu O, Dincq AS, Lessire S, Mullier F. Andexanet alfa for the reversal of factor Xa inhibitors. Expert Opin Biol Ther 2019; 19:387-397. [DOI: 10.1080/14712598.2019.1599355] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
- J Favresse
- Namur Thrombosis and Haemostasis Center, Hematology Laboratory, Université catholique de Louvain, CHU UCL Namur, Yvoir, Belgium
| | - M Hardy
- Department of Anesthesiology, CHU UCL Namur, Namur Thrombosis and Haemostasis Center, Université Catholique de Louvain, Yvoir, Belgium
| | - MA van Dievoet
- St-Luc University Hospital and Catholic University of Louvain, Department of Laboratory Medicine, Hematology Laboratory, Brussels, Belgium
| | - AL Sennesael
- Department of Pharmacy, Namur Thrombosis and Haemostasis Center, Namur Research Institute for Life Sciences, Namur, Belgium
| | - J Douxfils
- Department of Pharmacy, Namur Thrombosis and Haemostasis Center, Namur Research Institute for Life Sciences, Namur, Belgium
- Qualiblood s.a., Namur, Belgium
| | - CM Samama
- Department of Anaesthesiology and Intensive Care Medicine, Cochin University Hospital, Paris Descartes University, Paris, France
| | - O Vornicu
- Department of Anesthesiology, CHU UCL Namur, Namur Thrombosis and Haemostasis Center, Université Catholique de Louvain, Yvoir, Belgium
| | - AS Dincq
- Department of Anesthesiology, CHU UCL Namur, Namur Thrombosis and Haemostasis Center, Université Catholique de Louvain, Yvoir, Belgium
| | - S Lessire
- Department of Anesthesiology, CHU UCL Namur, Namur Thrombosis and Haemostasis Center, Université Catholique de Louvain, Yvoir, Belgium
| | - F Mullier
- Namur Thrombosis and Haemostasis Center, Hematology Laboratory, Université catholique de Louvain, CHU UCL Namur, Yvoir, Belgium
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