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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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2
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Stevens VM, Trujillo TC, Kiser TH, MacLaren R, Reynolds PM, Mueller SW. Retrospective Comparison of Andexanet Alfa and 4-Factor Prothrombin Complex for Reversal of Factor Xa-Inhibitor Related Bleeding. Clin Appl Thromb Hemost 2021; 27:10760296211039020. [PMID: 34541920 PMCID: PMC8642040 DOI: 10.1177/10760296211039020] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
The aim of this retrospective study was to compare andexanet alfa and 4-factor
prothrombin complex (4F-PCC) for reversal of factor Xa (FXa)-inhibitor bleeding.
Patients that received andexanet alfa for reversal were included. An equivalent
number of patients administered 4F-PCC for FXa-inhibitor bleeding were randomly
selected as historical controls. The primary outcome was effective hemostasis
achievement within 12 h, defined using ANNEXA-4 criteria. Thromboembolic events
and mortality within 30 days were also evaluated. A total of 32 patients were
included. Baseline characteristics were not statistically different between
andexanet alfa (n = 16) and 4F-PCC (n = 16). Intracranial bleeding was the
primary reversal indication in 43.8% versus 62.5% of patients, respectively.
Effective hemostasis was reached in 75.0% of andexanet alfa patients compared to
62.5% of 4F-PCC patients (P = .70). Thromboembolic events
occurred in 4 (25.0%) patients and 3 (18.8%) patients, respectively
(P = .99). Mortality incidence was 12.5% and 31.3%,
respectively (P = .39). Andexanet alfa and 4F-PCC attained
hemostasis in a majority of patients. A high, but a similar rate of
thromboembolic events was seen with both treatments. Prospective studies are
needed to elucidate comparative risks and benefits of the 2 agents.
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Affiliation(s)
- Victoria M Stevens
- 15503University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, 22095Aurora, CO, USA
| | - Toby C Trujillo
- 15503University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, 22095Aurora, CO, USA
| | - Tyree H Kiser
- 15503University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, 22095Aurora, CO, USA
| | - Robert MacLaren
- 15503University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, 22095Aurora, CO, USA
| | - Paul M Reynolds
- 15503University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, 22095Aurora, CO, USA
| | - Scott W Mueller
- 15503University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, 22095Aurora, CO, USA
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Vestal ML, Hodulik K, Mando-Vandrick J, James ML, Ortel TL, Fuller M, Notini M, Friedland M, Welsby IJ. Andexanet alfa and four-factor prothrombin complex concentrate for reversal of apixaban and rivaroxaban in patients diagnosed with intracranial hemorrhage. J Thromb Thrombolysis 2021; 53:167-175. [PMID: 34101050 DOI: 10.1007/s11239-021-02495-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/29/2021] [Indexed: 01/04/2023]
Abstract
Limited data exists regarding the clinical outcomes of andexanet alfa and four factor prothrombin complex concentrate (4F-PCC) for reversal of apixaban or rivaroxaban in the setting of intracranial hemorrhage (ICH). The objective of this study was to evaluate clinical outcomes of 4F-PCC and andexanet alfa for reversal of ICH associated with oral factor Xa inhibitors. This was a retrospective, single-center, case series evaluating hemostatic efficacy of patients receiving andexanet alfa) or 4F-PCC for reversal of apixaban or rivaroxaban after ICH. Secondary endpoints included in-hospital mortality, thrombotic complications, timing of reversal agents, intensive care unit and hospital length of stay, patient disposition, and 30-day readmission rate. During the study period, 21 patients received andexanet alfa and 35 received 4F-PCC. Hemostatic efficacy occurred in 64.7% of patients receiving andexanet alfa and 54.8% of receiving 4F-PCC. Thirty-day all-cause mortality was 45.2% for 4F-PCC and 30% for andexanet alfa. Thrombotic events were higher with 4F-PCC (31.4%) compared to andexanet alfa (14.3%). Median time from presentation to administration of reversal agent was 2.67 [1.75-4.13] hours with andexanet alfa and 1.73 [1.21-3.55] hours with 4F-PCC. Discharge to skilled nursing facilities and 30-day readmission were similar between groups. In this cohort, reversal with andexanet alfa and 4F-PCC differed in terms ofhemostatic efficacy and thrombotic events after ICH in patients anticoagulated with apixaban or rivaroxaban.
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Affiliation(s)
- Mark L Vestal
- Department of Pharmacy, Duke University Medical Center, Durham, NC, USA. .,Department of Pharmacy, Duke Regional Hospital, 3643 North Roxboro Street, Durham, NC, 27704, USA.
| | - Kimberly Hodulik
- Department of Pharmacy, Duke University Medical Center, Durham, NC, USA
| | | | - Michael L James
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA.,Department of Neurology, Duke University Medical Center, Durham, NC, USA
| | - Thomas L Ortel
- Division of Hematology, Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Matthew Fuller
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Maria Notini
- Clincial Laboratories, Duke University Medical Center, Durham, NC, USA
| | - Mark Friedland
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Ian J Welsby
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA.,Division of Hematology, Department of Medicine, Duke University Medical Center, Durham, NC, USA
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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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Jaspers T, Shudofsky K, Huisman MV, Meijer K, Khorsand N. A meta-analysis of andexanet alfa and prothrombin complex concentrate in the treatment of factor Xa inhibitor-related major bleeding. Res Pract Thromb Haemost 2021; 5:e12518. [PMID: 34084991 PMCID: PMC8143276 DOI: 10.1002/rth2.12518] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 03/14/2021] [Accepted: 03/16/2021] [Indexed: 11/08/2022] Open
Abstract
Background Andexanet alfa (andexanet) and prothrombin complex concentrate (PCC) are both reversal agents for major bleeding in patients using factor Xa inhibitors (FXaIs). Our aim was to evaluate the current evidence for the effectiveness and safety of andexanet and PCC in a systematic review and meta-analysis. Objectives Primary objective was hemostatic effectiveness. Secondary objectives were thromboembolic event rate and mortality. Methods A systematic review was performed in PubMed and Embase. Studies describing the effectiveness and/or safety of PCC or andexanet in patients with major bleeding using FXaIs were included. Meta-analysis was performed using a random-effects model. Results Seventeen PCC studies, 3 andexanet studies, and 1 study describing PCC and andexanet were included, comprising 1428 PCC-treated and 396 andexanet-treated patients. None of the included studies had control groups, hampering a pooled meta-analysis to compare the two reversal agents. Separate analyses for andexanet and PCC were performed. In subgroup analysis, the pooled proportion of patients with effective hemostasis in studies that used Annexa-4 criteria demonstrated a hemostatic effectiveness of 0.85 (95% confidence interval [CI], 0.80-0.90) in PCC and 0.82 (95% CI, 0.78-0.87) in andexanet studies. The pooled proportion of patients with thromboembolic events was 0.03 (95% CI, 0.02-0.04) in PCC and 0.11 (95% CI, 0.04-0.18) in andexanet studies. Conclusion Based on the available evidence with low certainty from observational studies, PCC and andexanet demonstrated a similar, effective hemostasis in the treatment of major bleeding in patients using FXaIs. Compared to PCC, the thromboembolic event rate appeared higher in andexanet-treated patients.
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Affiliation(s)
- Tessa Jaspers
- Department of Clinical Pharmacy and Pharmacology University Medical Centre Groningen Groningen The Netherlands
| | - Kimberly Shudofsky
- Department of Hospital Pharmacy Viecuri Medical Center Venlo The Netherlands
| | - Menno V Huisman
- Department of Thrombosis and Hemostasis Leiden University Medical Center Leiden The Netherlands
| | - Karina Meijer
- Department of Hematology University Medical Center Groningen Groningen The Netherlands
| | - Nakisa Khorsand
- Department of Hospital Pharmacy OLVG Amsterdam The Netherlands
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Andexanet Alfa or Prothrombin Complex Concentrate for Factor Xa Inhibitor Reversal in Acute Major Bleeding: A Systematic Review and Meta-Analysis. Crit Care Med 2021; 49:e1025-e1036. [PMID: 33967205 DOI: 10.1097/ccm.0000000000005059] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To combine evidence on andexanet alfa and prothrombin complex concentrates for factor Xa inhibitor-associated bleeding to guide clinicians on reversal strategies. DATA SOURCES Embase, Pubmed, Web of Science, and the Cochrane Library. STUDY SELECTION Observational studies and randomized clinical trials studying hemostatic effectiveness of andexanet alfa or prothrombin complex concentrate for acute reversal of factor Xa inhibitor-associated hemorrhage. DATA EXTRACTION Two independent reviewers extracted the data from the studies. Visualization and comparison of hemostatic effectiveness using Sarode et al or International Society of Thrombosis and Hemostasis Scientific and Standardization Committee criteria at 12 and 24 hours, (venous) thrombotic event rates, and inhospital mortality were performed by constructing Forest plots. Exploratory analysis using a logistic mixed model analysis was performed to identify factors associated with effectiveness and venous thromboembolic event. DATA SYNTHESIS A total of 21 studies were included (andexanet: 438 patients; prothrombin complex concentrate: 1,278 patients). The (weighted) mean effectiveness for andexanet alfa was 82% at 12 hours and 71% at 24 hours. The (weighted) mean effectiveness for prothrombin complex concentrate was 88% at 12 hours and 76% at 24 hours. The mean 30-day symptomatic venous thromboembolic event rates were 5.0% for andexanet alfa and 1.9% for prothrombin complex concentrate. The mean 30-day total thrombotic event rates for andexanet alfa and prothrombin complex concentrate were 10.7% and 3.1%, respectively. Mean inhospital mortality was 23.3% for andexanet versus 15.8% for prothrombin complex concentrate. Exploratory analysis controlling for potential confounders did not demonstrate significant differences between both reversal agents. CONCLUSIONS Currently, available evidence does not unequivocally support the clinical effectiveness of andexanet alfa or prothrombin complex concentrate to reverse factor Xa inhibitor-associated acute major bleeding, nor does it permit conventional meta-analysis of potential superiority. Neither reversal agent was significantly associated with increased effectiveness or a higher rate of venous thromboembolic event. These results underscore the importance of randomized controlled trials comparing the two reversal agents and may provide guidance in designing institutional guidelines.
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Hormese M, Littler A, Doane B, Glowacki N, Khimani A, Vivacqua N, Rudenberg K. Comparison of high- and low-dose 4-factor prothrombin complex concentrate for the emergent reversal of oral Factor Xa inhibitors. J Thromb Thrombolysis 2021; 52:828-835. [PMID: 33725284 DOI: 10.1007/s11239-021-02412-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/16/2021] [Indexed: 11/28/2022]
Abstract
Even though there are several reversal strategies available for oral Factor Xa inhibitor associated coagulopathies, 4-factor prothrombin complex concentrate (4F-PCC) is used commonly as the primary reversal agent at many institutions. A dose of 50 units/kg is recommended as safe and effective with growing data suggesting that a lower dosing strategy may be sufficient. This retrospective study included adult patients who received either high-dose (50 units/kg; maximum dose: 5000 units) or low-dose (25 units/kg; maximum dose: 2500 units) 4F-PCC for the emergent reversal of oral Factor Xa inhibitor-related life threatening bleeding. The primary outcome was the attainment of hemostatic effectiveness. Secondary outcomes were rates of thromboembolic events and inpatient mortality. 47 patients were included in the analysis of which 24 patients received high-dose and 23 patients received low-dose 4F-PCC. Overall hemostatic effectiveness was 87.5% in the high-dose group and 91.3% in the low-dose group. Thromboembolic event rate was 8.3% in the high-dose group compared to 4.4% within the low-dose group and inpatient mortality rate was 8.3% in the high-dose group and 4.4% in the low-dose group. Low-dose 4F-PCC (25 units/kg, maximum dose: 2500 units) for the reversal of oral Factor Xa inhibitors is a cost-effective alternative to high-dose 4F-PCC (50 units/kg; maximum dose: 5000 units) and provides effective hemostasis without increased rates of thromboembolic events or inpatient mortality.
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Affiliation(s)
- Mary Hormese
- Department of Pharmacy, Northwest Community Hospital, Arlington Heights, USA.
| | - Alex Littler
- Department of Pharmacy, AMITA Health Saint Francis Hospital, Evanston, USA
| | - Brian Doane
- Department of Emergency Medicine, Northwest Community Hospital, Arlington Heights, USA
| | - Nicole Glowacki
- Advocate Aurora Research Institute, Advocate Aurora Health, Milwaukee, WI, USA
| | - Ann Khimani
- Department of Neurointerventional Radiology, Northwest Community Hospital, Arlington Heights, USA
| | - Nicole Vivacqua
- Department of Pharmacy, Northwest Community Hospital, Arlington Heights, USA
| | - Karina Rudenberg
- Department of Pharmacy, Northwest Community Hospital, Arlington Heights, USA
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Highsmith EA, Morton C, Varnado S, Donahue KR, Sulhan S, Lista A. Outcomes Associated With 4-Factor Prothrombin Complex Concentrate Administration to Reverse Oral Factor Xa Inhibitors in Bleeding Patients. J Clin Pharmacol 2020; 61:598-605. [PMID: 33094836 DOI: 10.1002/jcph.1779] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Accepted: 10/19/2020] [Indexed: 12/20/2022]
Abstract
Compared with vitamin K antagonists (VKAs), oral factor Xa inhibitors are associated with at least equivalent efficacy and a lower incidence of major bleeding. Despite this benefit, bleeding remains the most common adverse event. Prior to the approval of andexanet alfa, alternative agents such as 4-factor prothrombin complex concentrate (4F-PCC) were utilized for reversal. This was a retrospective, descriptive study conducted on patients 18 years of age or older who received 4F-PCC for reversal of oral factor Xa inhibitors-associated bleeding. Patients were excluded if they received a VKA or dabigatran in the previous 48 hours. A subgroup analysis comparing 4F-PCC with andexanet alfa was conducted on patients who met the inclusion and exclusion criteria of the ANNEXA-4 trial. The primary end point of this study was to evaluate the incidence of hemostasis and associated dosing strategies in patients receiving 4F-PCC for reversal of oral factor Xa inhibitors-associated bleeding. Thirty-eight patients were included, and 28 patients (74%) achieved hemostasis. The median dose of 4F-PCC was 50 units/kg. In patients who achieved hemostasis, the median dose was 50 units/kg, and in those who failed to reach hemostasis, a median dose of 30 units/kg was seen. Within the subgroup analysis, there was no difference in overall rates of hemostasis between the 4F-PCC and andexanet alfa groups. Remaining a reasonable option to utilize for reversal of oral factor Xa inhibitors is 4F-PCC, especially when andexanet alfa is unavailable, with 50 units/kg appearing to be the most effective dose to achieve hemostasis. Further studies are needed to determine a preferential agent.
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Costa OS, Baker WL, Roman-Morillo Y, McNeil-Posey K, Lovelace B, White CM, Coleman CI. Quality evaluation of case series describing four-factor prothrombin complex concentrate in oral factor Xa inhibitor-associated bleeding: a systematic review. BMJ Open 2020; 10:e040499. [PMID: 33154059 PMCID: PMC7646359 DOI: 10.1136/bmjopen-2020-040499] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 10/05/2020] [Accepted: 10/18/2020] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION As oral factor Xa (oFXa) inhibitor use has increased, so has publication of case series describing related bleeding managed with four-factor prothrombin complex concentrate (4F-PCC). OBJECTIVE This review aimed to identify case series describing 4F-PCC management of oFXa inhibitor-related bleeding and appraise their methodological and reporting quality. DESIGN We searched Medline and EMBASE (1 January 2011 to 31 May 2020) to identify series of ≥10 patients with oFXa inhibitor-related major bleeding given off-label 4F-PCC. Case series were evaluated using a validated tool adapted for this topic. The tool addressed patient selection, bleed/outcome ascertainment, causal/temporal association and reporting. RESULTS We identified 14 case series. None had ≥100 patients (range=13-84), three were prospective, two detailed appropriate inclusion criteria and four noted consecutive inclusion. While 12 series provided clear/appropriate methods for diagnosis of intracranial haemorrhage (ICH); none did so for extracranial bleeds and it was not clear whether bleeding was adjudicated in any. Haemostatic effectiveness, thrombosis and mortality were together evaluated in 12 series, but only seven used validated methods to evaluate/diagnosis haemostasis in ICH, six in gastrointestinal bleeds, five in other bleeds and three in thrombosis. Independent adjudication of haemostasis (n=1) and thrombosis (n=2) was infrequent. Thirty-day follow-up for mortality and thrombosis was noted in five and seven series. Anticoagulation measurement/levels in at least some patients were conveyed in three series. Few series provided data on anticoagulant agent/dose (n=4), time from anticoagulant (n=4), time-to-reversal (n=7), baseline (n=7) or change (n=0) in neurologic function. CONCLUSIONS Although many case series describe off-label use of 4F-PCC for oFXa inhibitor-related bleeding, methodological flaws and/or poor reporting necessitates caution in interpretation.
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Affiliation(s)
- Olivia S Costa
- Pharmacy Practice, University of Connecticut School of Pharmacy, Storrs, Connecticut, USA
- Evidence-Based Practice Center, Hartford Hospital, Hartford, Connecticut, USA
| | - William L Baker
- Pharmacy Practice, University of Connecticut School of Pharmacy, Storrs, Connecticut, USA
- Evidence-Based Practice Center, Hartford Hospital, Hartford, Connecticut, USA
| | - Yuani Roman-Morillo
- Pharmacy Practice, University of Connecticut School of Pharmacy, Storrs, Connecticut, USA
- Evidence-Based Practice Center, Hartford Hospital, Hartford, Connecticut, USA
| | - Kelly McNeil-Posey
- Health Economics and Outcomes Research, Portola Pharmaceuticals Inc, South San Francisco, California, USA
| | - Belinda Lovelace
- Health Economics and Outcomes Research, Portola Pharmaceuticals Inc, South San Francisco, California, USA
| | - C Michael White
- Pharmacy Practice, University of Connecticut School of Pharmacy, Storrs, Connecticut, USA
- Evidence-Based Practice Center, Hartford Hospital, Hartford, Connecticut, USA
| | - Craig I Coleman
- Pharmacy Practice, University of Connecticut School of Pharmacy, Storrs, Connecticut, USA
- Evidence-Based Practice Center, Hartford Hospital, Hartford, Connecticut, USA
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