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Levy JH, Shaw JR, Castellucci LA, Connors JM, Douketis J, Lindhoff-Last E, Rocca B, Samama CM, Siegal D, Weitz JI. Reversal of direct oral anticoagulants: guidance from the SSC of the ISTH. J Thromb Haemost 2024:S1538-7836(24)00426-4. [PMID: 39029742 DOI: 10.1016/j.jtha.2024.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2024] [Revised: 07/04/2024] [Accepted: 07/08/2024] [Indexed: 07/21/2024]
Abstract
The currently approved direct oral anticoagulants (DOACs) are increasingly used in clinical practice. Although serious bleeding risks are lower with DOACs than with vitamin K antagonists, bleeding remains the most frequent side effect. Andexanet alfa and idarucizumab are the currently approved specific reversal agents for oral factor (F)Xa inhibitors and dabigatran, respectively. Our prior guidance document was published in 2016, but with more information available on the utility and increased use of these reversal agents and other bleeding management strategies, we have updated this International Society on Thrombosis and Haemostasis guidance document on DOAC reversal. In this narrative review, we compare the mechanism of action of specific and nonspecific reversal agents, review the clinical data supporting their use, and provide guidance on when reversal is indicated. In addition, we briefly discuss the reversal of oral FXIa inhibitors, a new class of DOACs currently under clinical development.
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Affiliation(s)
- Jerrold H Levy
- Department of Anesthesiology, Critical Care, and Surgery, Duke University School of Medicine, Durham, North Carolina, USA.
| | - Joseph R Shaw
- Department of Medicine, Division of Hematology, University of Ottawa, Ottawa, Ontario, Canada
| | - Lana A Castellucci
- Department of Medicine, Ottawa Hospital Research Institute at the University of Ottawa, Ottawa, Ontario, Canada
| | - Jean M Connors
- Hematology Division Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - James Douketis
- Department of Medicine, Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Edelgard Lindhoff-Last
- Department of Vascular Medicine and Hemostaseology, Coagulation Research Centre Bethanien Hospital, Frankfurt, Germany
| | - Bianca Rocca
- Department of Safety and Bioethics-Section of Pharmacology, Catholic University School of Medicine, Rome, Italy; NeuroFarBa Department, University of Florence, Florence, Italy
| | - Charles Marc Samama
- Department of Anaesthesia, Intensive Care and Perioperative Medicine, Groupement Hospitalier Universitaire Assistance Publique - Hôpitaux de Paris Centre, Université Paris Cité, Paris, France
| | - Deborah Siegal
- Department of Medicine, Ottawa Hospital Research Institute at the University of Ottawa, Ottawa, Ontario, Canada
| | - Jeffrey I Weitz
- Departments of Medicine and Biochemistry and Biomedical Sciences, McMaster University and the Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada
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2
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Orso D, Fonda F, Brussa A, Comisso I, Auci E, Sartori M, Bove T. Andexanet alpha versus four-factor prothrombin complex concentrate in DOACs anticoagulation reversal: an updated systematic review and meta-analysis. Crit Care 2024; 28:221. [PMID: 38970010 PMCID: PMC11225147 DOI: 10.1186/s13054-024-05014-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2024] [Accepted: 07/01/2024] [Indexed: 07/07/2024] Open
Abstract
BACKGROUND There is currently a lack of evidence for the comparative effectiveness of Andexanet alpha and four-factor prothrombin complex concentrate (4F-PCC) in anticoagulation reversal of direct oral anticoagulants (DOACs). The primary aim of our systematic review was to verify which drug is more effective in reducing short-term all-cause mortality. The secondary aim was to determine which of the two reverting strategies is less affected by thromboembolic events. METHODS A systematic review and meta-analysis was performed. RESULTS Twenty-two studies were analysed in the systematic review and quantitative synthesis. In all-cause short-term mortality, Andexanet alpha showed a risk ratio (RR) of 0.71(95% CI 0.37-1.34) in RCTs and PSMs, compared to 4F-PCC (I2 = 81%). Considering the retrospective studies, the pooled RR resulted in 0.84 (95% CI 0.69-1.01) for the common effects model and 0.82 (95% CI 0.63-1.07) for the random effects model (I2 = 34.2%). Regarding the incidence of thromboembolic events, for RCTs and PSMs, the common and the random effects model exhibited a RR of 1.74 (95% CI 1.09-2.77), and 1.71 (95% CI 1.01-2.89), respectively, for Andexanet alpha compared to 4F-PCC (I2 = 0%). Considering the retrospective studies, the pooled RR resulted in 1.21 (95% CI 0.87-1.69) for the common effects model and 1.18 (95% CI 0.86-1.62) for the random effects model (I2 = 0%). CONCLUSION Considering a large group of both retrospective and controlled studies, Andexanet alpha did not show a statistically significant advantage over 4F-PCC in terms of mortality. In the analysis of the controlled studies alone, Andexanet alpha is associated with an increased risk of thromboembolic events. CLINICAL TRIAL REGISTRATION PROSPERO: International prospective register of systematic reviews, 2024, CRD42024548768.
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Affiliation(s)
- Daniele Orso
- Azienda Sanitaria Universitaria Friuli Centrale, Department of Emergency "Santa Maria Della Misericordia", University Hospital of Udine, Piazzale Santa Maria Della Misericordia, N.15, 33100, Udine, UD, Italy.
- Department of Medicine, University of Udine, via Colugna 50, 33100, Udine, Italy.
| | - Federico Fonda
- Azienda Sanitaria Universitaria Friuli Centrale, Department of Emergency "Santa Maria Della Misericordia", University Hospital of Udine, Piazzale Santa Maria Della Misericordia, N.15, 33100, Udine, UD, Italy
| | - Alessandro Brussa
- Azienda Sanitaria Universitaria Friuli Centrale, Department of Emergency "Santa Maria Della Misericordia", University Hospital of Udine, Piazzale Santa Maria Della Misericordia, N.15, 33100, Udine, UD, Italy
| | - Irene Comisso
- Azienda Sanitaria Universitaria Friuli Centrale, Department of Emergency "Santa Maria Della Misericordia", University Hospital of Udine, Piazzale Santa Maria Della Misericordia, N.15, 33100, Udine, UD, Italy
| | - Elisabetta Auci
- Azienda Sanitaria Universitaria Friuli Centrale, Department of Emergency "Santa Maria Della Misericordia", University Hospital of Udine, Piazzale Santa Maria Della Misericordia, N.15, 33100, Udine, UD, Italy
| | - Marco Sartori
- Azienda Sanitaria Universitaria Friuli Centrale, Department of Emergency "Santa Maria Della Misericordia", University Hospital of Udine, Piazzale Santa Maria Della Misericordia, N.15, 33100, Udine, UD, Italy
| | - Tiziana Bove
- Azienda Sanitaria Universitaria Friuli Centrale, Department of Emergency "Santa Maria Della Misericordia", University Hospital of Udine, Piazzale Santa Maria Della Misericordia, N.15, 33100, Udine, UD, Italy
- Department of Medicine, University of Udine, via Colugna 50, 33100, Udine, Italy
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3
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Whaley PM, Franco-Martinez C, Lock AE, Ramaswamy D, Young EH, Allen SM, Barthol CA. Hemostatic Efficacy and Safety of 4-Factor Prothrombin Complex Concentrate in Doac-Associated Intracranial Hemorrhage. J Pharm Pract 2024; 37:557-562. [PMID: 36564900 DOI: 10.1177/08971900221148034] [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: 12/25/2022]
Abstract
Background: Factor Xa (FXa) inhibitor use has increased over the last decade and though associated rates of major bleeding are lower compared to warfarin, outcomes from intracranial hemorrhage (ICH) are still significant. Targeted FXa inhibitor reversal agent became available in 2018, however use of 4-factor prothrombin complex concentrate (4F-PCC) for FXa inhibitor-associated ICH continues at many institutions. Objective: Evaluate the safety and hemostatic efficacy of 4F-PCC for FXa inhibitor-associated ICH. Methods: Single-center, retrospective study of patients who received 4F-PCC for FXa inhibitor-associated ICH. The primary efficacy endpoint was hemostasis and thrombosis was the main safety endpoint. Secondary endpoints included in-hospital mortality and discharge disposition. Results: 76 patients on apixaban or rivaroxaban were included. Good or excellent hemostasis was achieved in 80.3% of patients. Five patients experienced a thrombotic event. Favorable discharge disposition and lower in-hospital mortality was more likely in patients who achieved excellent hemostasis. Conclusion: 4F-PCC is safe and effective for FXa inhibitor associated ICH.
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Affiliation(s)
- Patrick M Whaley
- University Health, San Antonio, TX, USA
- UT Health San Antonio, San Antonio, TX, USA
- The University of Texas at Austin College of Pharmacy, Pharmacotherapy Division, Austin, TX, USA
| | - Crystal Franco-Martinez
- University Health, San Antonio, TX, USA
- UT Health San Antonio, San Antonio, TX, USA
- The University of Texas at Austin College of Pharmacy, Pharmacotherapy Division, Austin, TX, USA
| | - Ashley E Lock
- University Health, San Antonio, TX, USA
- UT Health San Antonio, San Antonio, TX, USA
- The University of Texas at Austin College of Pharmacy, Pharmacotherapy Division, Austin, TX, USA
| | - Davana Ramaswamy
- University Health, San Antonio, TX, USA
- UT Health San Antonio, San Antonio, TX, USA
| | - Eric H Young
- The University of Texas at Austin College of Pharmacy, Pharmacotherapy Division, Austin, TX, USA
| | - Stefan M Allen
- The University of Texas at Austin College of Pharmacy, Pharmacotherapy Division, Austin, TX, USA
| | - Colleen A Barthol
- University Health, San Antonio, TX, USA
- UT Health San Antonio, San Antonio, TX, USA
- The University of Texas at Austin College of Pharmacy, Pharmacotherapy Division, Austin, TX, USA
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4
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Ferreira LO, Oldemburg RAL, Leitão Filho JM, Cerveira RA, Vasconcelos VW, da Costa GE, Rodrigues RDR, Lopes DCF. Andexanet Alfa versus Four-Factor Prothrombin Complex Concentrate for the Reversal of Factor Xa (FXa) Inhibitor-Associated Intracranial Hemorrhage: A Systematic Review of Retrospective Studies. J Clin Med 2024; 13:3077. [PMID: 38892788 PMCID: PMC11173120 DOI: 10.3390/jcm13113077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Revised: 04/03/2024] [Accepted: 04/04/2024] [Indexed: 06/21/2024] Open
Abstract
Background/Objectives: There are limited data on the risks and benefits of using Andexanet alfa (AA) compared with four-factor prothrombin complex concentrate (4F-PCC) for the reversal of factor Xa inhibitor-associated intracranial hemorrhage (ICH). Our aim was to describe a compilation of the information available in the literature to date. Methods: PubMed, Embase, Web of Science (Clarivate Analytics) and the Cochrane Central Register of Controlled Trials were searched until December 2023. Following the "Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)" guidelines, our systematic literature review included studies that were retrospective in design and evaluated both drugs to control bleeding and complications (death and thromboembolic events). Two researchers re-examined the studies for relevance, extracted the data and assessed the risk of bias. No meta-analyses were performed for the results. Results: In this limited patient sample, we found no differences between published articles in terms of neuroimaging stability or thrombotic events. However, some studies show significant differences in mortality, suggesting that one of the AAs may be superior to 4F-PCC. Conclusions: Our qualitative analysis shows that AA has a better efficacy profile compared with 4F-PCC. However, further studies monitoring these patients and a multicenter collaborative network dedicated to this topic are needed.
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Affiliation(s)
- Luan Oliveira Ferreira
- Department of Anesthesiology, João de Barros Barreto University Hospital, Belém 66073-000, Brazil; (R.A.L.O.); (J.M.L.F.); (V.W.V.); (G.E.d.C.)
| | - Ricardo Andres León Oldemburg
- Department of Anesthesiology, João de Barros Barreto University Hospital, Belém 66073-000, Brazil; (R.A.L.O.); (J.M.L.F.); (V.W.V.); (G.E.d.C.)
| | - João Monteiro Leitão Filho
- Department of Anesthesiology, João de Barros Barreto University Hospital, Belém 66073-000, Brazil; (R.A.L.O.); (J.M.L.F.); (V.W.V.); (G.E.d.C.)
| | - Rodrigo Arcoverde Cerveira
- Division of Immunology & Allergy, Department of Medicine Solna, Karolinska Institutet, Karolinska University Hospital, SE-171 76 Stockholm, Sweden;
- Center for Molecular Medicine, Karolinska Institutet, Karolinska University Hospital, SE-171 76 Stockholm, Sweden
| | - Victoria Winkler Vasconcelos
- Department of Anesthesiology, João de Barros Barreto University Hospital, Belém 66073-000, Brazil; (R.A.L.O.); (J.M.L.F.); (V.W.V.); (G.E.d.C.)
| | - Giovana Escribano da Costa
- Department of Anesthesiology, João de Barros Barreto University Hospital, Belém 66073-000, Brazil; (R.A.L.O.); (J.M.L.F.); (V.W.V.); (G.E.d.C.)
| | - Roseny dos Reis Rodrigues
- Department of Anesthesiology, São Paulo University, São Paulo 05403-010, Brazil;
- Intensive Care Department, Albert Einstein Hospital, São Paulo 05652-900, Brazil
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5
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Phillips A, Bradley C, Cash J, Sangiovanni R, Wingerson C. Effect of low- versus high-dose 4-factor prothrombin complex concentrate in factor Xa inhibitor-associated bleeding: A qualitative systematic review. Am J Health Syst Pharm 2024; 81:e274-e282. [PMID: 38430127 DOI: 10.1093/ajhp/zxae009] [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: 01/19/2024] [Indexed: 03/03/2024] Open
Abstract
PURPOSE The purpose of this review is to evaluate current literature on the treatment of factor Xa inhibitor-associated bleeds with 4-factor prothrombin complex concentrate (4F-PCC), with a focus on the effect of low versus high dosing of 4F-PCC on hemostatic efficacy and safety outcomes. SUMMARY A search of PubMed and EBSCOhost was performed to identify studies evaluating patients with a factor Xa inhibitor-bleed treated with 4F-PCC at either low or high doses. Studies of patients receiving alternative reversal agents such as fresh frozen plasma and andexanet alfa or where no comparator group was evaluated were excluded from the analysis. To assess the effect of these 4F-PCC dosing strategies, the primary outcome of interest was hemostatic efficacy. Four studies meeting inclusion criteria were included in this review. In each of the included studies, similar rates of hemostatic efficacy, hospital mortality, and venous thromboembolism were observed in the low- and high-dose cohorts. CONCLUSION These results suggest low- and high-dose 4F-PCC may confer similar clinical effectiveness and safety; however, these findings should be evaluated and confirmed with future prospective studies.
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Affiliation(s)
- Anna Phillips
- Presbyterian College School of Pharmacy, Clinton, SC, USA
| | - Colby Bradley
- Presbyterian College School of Pharmacy, Clinton, SC, USA
| | - Julie Cash
- Presbyterian College School of Pharmacy, Clinton, SC, USA
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6
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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. Reply to "Letter to Dobesh et al. on lower mortality with andexanet alfa in factor Xa inhibitor-related major bleeding". Res Pract Thromb Haemost 2024; 8:102429. [PMID: 38993619 PMCID: PMC11238041 DOI: 10.1016/j.rpth.2024.102429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Accepted: 04/17/2024] [Indexed: 07/13/2024] Open
Affiliation(s)
- Paul P Dobesh
- Department of Pharmacy Practice and Science, 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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7
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White CM, Caroti KS, Bessada Y, Hernandez AV, Baker WL, Dobesh PP, van Haalen H, Rhodes K, Coleman CI. Andexanet alfa versus PCC products for factor Xa inhibitor bleeding: A systematic review with meta-analysis. Pharmacotherapy 2024; 44:394-408. [PMID: 38721837 DOI: 10.1002/phar.2925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 04/12/2024] [Accepted: 04/12/2024] [Indexed: 06/11/2024]
Abstract
Previous meta-analyses assessed andexanet alfa (AA) or prothrombin complex concentrate (PCC) products for the treatment of Factor Xa inhibitor (FXaI)-associated major bleeding. However, they did not include recent studies or assess the impact of the risk of bias. We conducted a systematic review with meta-analysis on the effectiveness of AA versus PCC products for FXaI-associated major bleeding, inclusive of the studies' risk of bias. PubMed and Embase were searched for comparative studies assessing major bleeding in patients using FXaI who received AA or PCC. We used the Methodological Index for NOn-Randomized Studies (MINORS) checklist and one question from the Joanna Briggs Institute (JBI) Critical Appraisal of Case Series tool to assess the risk of bias. Random-effects meta-analyses were performed to provide a pooled estimate for the effect of AA versus PCC products on hemostatic efficacy, in-hospital mortality, 30-day mortality, and thrombotic events. Low-moderate risk of bias studies were meta-analyzed separately, as well as combined with high risk of bias studies. Eighteen comparative evaluations of AA versus PCC were identified. Twenty-eight percent of the studies (n = 5) had low-moderate risk and 72% (n = 13) had a high risk of bias. Studies with low-moderate risk of bias suggested improvements in hemostatic efficacy [Odds Ratio (OR) 2.72 (95% Confidence Interval (CI): 1.15-6.44); one study], lower in-hospital mortality [OR 0.48 (95% CI: 0.38-0.61); three studies], and reduced 30-day mortality [OR 0.49 (95% CI: 0.30-0.80); two studies] when AA was used versus PCC products. When studies were included regardless of the risk of bias, pooled effects showed improvements in hemostatic efficacy [OR 1.36 (95% CI: 1.01-1.84); 12 studies] and reductions in 30-day mortality [OR 0.53 (95% CI: 0.37-0.76); six studies] for AA versus PCC. The difference in thrombotic events with AA versus PCC was not statistically significant in the low-moderate, high, or combined risk of bias groups. The evidence from low-moderate quality real-world studies suggests that AA is superior to PCC in enhancing hemostatic efficacy and reducing in-hospital and 30-day mortality. When studies are assessed regardless of the risk of bias, the pooled hemostatic efficacy and 30-day mortality risk remain significantly better with AA versus PCC.
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Affiliation(s)
- C Michael White
- University of Connecticut School of Pharmacy, Storrs, Connecticut, USA
- Hartford Hospital Health Outcomes, Policy and Evidence Synthesis Group, Hartford, Connecticut, USA
| | - Kimberly Snow Caroti
- University of Connecticut School of Pharmacy, Storrs, Connecticut, USA
- Hartford Hospital Health Outcomes, Policy and Evidence Synthesis Group, Hartford, Connecticut, USA
| | - Youssef Bessada
- University of Connecticut School of Pharmacy, Storrs, Connecticut, USA
| | - Adrian V Hernandez
- University of Connecticut School of Pharmacy, Storrs, Connecticut, USA
- Hartford Hospital Health Outcomes, Policy and Evidence Synthesis Group, Hartford, Connecticut, USA
- Unidad de Revisiones Sistemáticas y Meta-análisis (URSIGET), Vicerrectorado de Investigación, Universidad San Ignacio de Loyola, Lima, Peru
| | - William L Baker
- University of Connecticut School of Pharmacy, Storrs, Connecticut, USA
- Hartford Hospital Health Outcomes, Policy and Evidence Synthesis Group, Hartford, Connecticut, USA
| | - Paul P Dobesh
- University of Nebraska Medical Center College of Pharmacy, Omaha, Nebraska, USA
| | | | - Kirsty Rhodes
- Medical and Payer Evidence, BioPharmaceuticals Medical, AstraZeneca, Cambridge, UK
| | - Craig I Coleman
- University of Connecticut School of Pharmacy, Storrs, Connecticut, USA
- Hartford Hospital Health Outcomes, Policy and Evidence Synthesis Group, Hartford, Connecticut, USA
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8
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Grottke O, Afshari A, Ahmed A, Arnaoutoglou E, Bolliger D, Fenger-Eriksen C, von Heymann C. Clinical guideline on reversal of direct oral anticoagulants in patients with life threatening bleeding. Eur J Anaesthesiol 2024; 41:327-350. [PMID: 38567679 DOI: 10.1097/eja.0000000000001968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
BACKGROUND Anticoagulation is essential for the treatment and prevention of thromboembolic events. Current guidelines recommend direct oral anticoagulants (DOACs) over vitamin K antagonists in DOAC-eligible patients. The major complication of anticoagulation is serious or life-threatening haemorrhage, which may necessitate prompt haemostatic intervention. Reversal of DOACs may also be required for patients in need of urgent invasive procedures. This guideline from the European Society of Anaesthesiology and Intensive Care (ESAIC) aims to provide evidence-based recommendations and suggestions on how to manage patients on DOACs undergoing urgent or emergency procedures including the treatment of DOAC-induced bleeding. DESIGN A systematic literature search was performed, examining four drug comparators (dabigatran, rivaroxaban, apixaban, edoxaban) and clinical scenarios ranging from planned to emergency surgery with the outcomes of mortality, haematoma growth and thromboembolic complications. The GRADE (Grading of Recommendations, Assessment, Development and Evaluation) methodology was used to assess the methodological quality of the included studies. Consensus on the wording of the recommendations was achieved by a Delphi process. RESULTS So far, no results from prospective randomised trials comparing two active comparators (e.g. a direct reversal agent and an unspecific haemostatic agent such as prothrombin complex concentrate: PCC) have been published yet and the majority of publications were uncontrolled and observational studies. Thus, the certainty of evidence was assessed to be either low or very low (GRADE C). Thirty-five recommendations and clinical practice statements were developed. During the Delphi process, strong consensus (>90% agreement) was achieved in 97.1% of recommendations and consensus (75 to 90% agreement) in 2.9%. DISCUSSION DOAC-specific coagulation monitoring may help in patients at risk for elevated DOAC levels, whereas global coagulation tests are not recommended to exclude clinically relevant DOAC levels. In urgent clinical situations, haemostatic treatment using either the direct reversal or nonspecific haemostatic agents should be started without waiting for DOAC level monitoring. DOAC levels above 50 ng ml-1 may be considered clinically relevant necessitating haemostatic treatment before urgent or emergency procedures. Before cardiac surgery under activated factor Xa (FXa) inhibitors, the use of andexanet alfa is not recommended because of inhibition of unfractionated heparin, which is needed for extracorporeal circulation. In the situation of DOAC overdose without bleeding, no haemostatic intervention is suggested, instead measures to eliminate the DOACs should be taken. Due to the lack of published results from comparative prospective, randomised studies, the superiority of reversal treatment strategy vs. a nonspecific haemostatic treatment is unclear for most urgent and emergency procedures and bleeding. Due to the paucity of clinical data, no recommendations for the use of recombinant activated factor VII as a nonspecific haemostatic agent can be given. CONCLUSION In the clinical scenarios of DOAC intake before urgent procedures and DOAC-induced bleeding, practitioners should evaluate the risk of bleeding of the procedure and the severity of the DOAC-induced bleeding before initiating treatment. Optimal reversal strategy remains to be determined in future trials for most clinical settings.
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Affiliation(s)
- Oliver Grottke
- From the Department of Anaesthesiology, RWTH Aachen University Hospital, Pauwelsstrasse, Aachen, Germany (OG), Department of Paediatric and Obstetric Anaesthesia, Juliane Marie Centre, Rigshospitalet; & Department of Clinical Medicine, Copenhagen University, Denmark (AA), Department of Anaesthesia and Critical Care, Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester (AA), Department of Cardiovascular Sciences, University of Leicester, Leicester, UK (AA), Department of Anaesthesiology, Larissa University Hospital, Larissa, Greece (EA), Clinic for Anaesthesia, Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Spitalstrasse, Basel, Switzerland (DB), Department of Anaesthesiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard, Aarhus, Denmark (CF-E) and Department of Anaesthesia, Intensive Care Medicine, Emergency Medicine and Pain Therapy, Vivantes Klinikum im Friedrichshain, Landsberger Allee, Berlin, Germany (CvH)
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9
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Buka RJ, Sutton DJ, Nicolson PL. Enoxaparin is not an oral factor Xa inhibitor. Response to Sutton et al. real-world clinical outcomes among US veterans with oral factor Xa inhibitor-related major bleeding treated with andexanet alfa or 4-factor prothrombin complex concentrate. J Thromb Thrombolysis 2024; 57:739-741. [PMID: 38358568 DOI: 10.1007/s11239-024-02948-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/04/2024] [Indexed: 02/16/2024]
Affiliation(s)
- Richard J Buka
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK.
| | - David J Sutton
- Staffordshire Thrombosis and Anticoagulation Service, University Hospitals North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Phillip Lr Nicolson
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
- Department of Clinical Haematology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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10
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De Luca L, Pugliese FR, Susi B, Navazio A, Corda M, Fabbri A, Scicchitano P, Voza A, Vanni S, Bilato C, Geraci G, Gabrielli D, Grimaldi M, Colivicchi F, De Iaco F, Oliva F. ANMCO/SIMEU consensus document on the use of reversal agents for antithrombotic therapies in patients with ongoing bleeding or at high risk of haemorrhagic events. Eur Heart J Suppl 2024; 26:ii211-ii220. [PMID: 38784674 PMCID: PMC11110459 DOI: 10.1093/eurheartjsupp/suae033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
In recent decades, an incredible evolution in antithrombotic therapies used for treating patients with atherosclerosis, atrial fibrillation, and venous thromboembolism has been observed, leading to the availability of increasingly safe drugs. Nonetheless, bleeding complications remain a significant concern, with considerable health, social, and economic implications. To improve the acute management of patients experiencing or at risk for major bleeding events, specific reversal agents for antithrombotic drugs have been recently developed. While these agents demonstrate effectiveness in small-scale pharmacodynamic studies and clinical trials, it is imperative to balance the benefits of reversing antiplatelet or anticoagulant therapy against the risk of prothrombotic effects. These risks include the potential loss of antithrombotic protection and the prothrombotic tendencies associated with bleeding, major surgery, or trauma. This joint document of the Italian Association of Hospital Cardiologists (Associazione Nazionale Medici Cardiologi Ospedalieri) and the Italian Society of Emergency Medicine (Società Italiana di Medicina d'Emergenza-Urgenza) delineates the key features and efficacy of available reversal agents. It also provides practical flowcharts to guide their use in patients with active bleeding or those at elevated risk of major bleeding events.
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Affiliation(s)
- Leonardo De Luca
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Viale Camillo Golgi 19, 27100 Pavia, Italy
| | | | - Beniamino Susi
- Dipartimento di Emergenza, Policlinico Tor Vergata, Rome, Italy
| | - Alessandro Navazio
- S.O.C. Cardiologia Ospedaliera, Presidio Ospedaliero Arcispedale Santa Maria Nuova, Azienda USL di Reggio Emilia—IRCCS, Reggio Emilia, Italy
| | - Marco Corda
- S.C. Cardiologia, Azienda Ospedaliera G. Brotzu, Cagliari, Italy
| | - Andrea Fabbri
- Dipartimento di Emergenza, AUSL Romagna, Presidio Ospedaliero Morgagni-Pierantoni, Forlì, Italy
| | | | - Antonio Voza
- Dipartimento di Scienze Biomediche, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Simone Vanni
- Dipartimento Medicina Sperimentale e Clinica, Università degli Studi di Firenze, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Claudio Bilato
- U.O.C. Cardiologia, Ospedali dell’Ovest Vicentino, Azienda ULSS 8 Berica, Vicenza, Italy
| | - Giovanna Geraci
- U.O.C. Cardiologia, Ospedale Sant’Antonio Abate, Trapani, Italy
| | - Domenico Gabrielli
- Dipartimento Cardio-Toraco-Vascolare, U.O.C. Cardiologia, Azienda Ospedaliera San Camillo Forlanini, Roma, Italy
| | - Massimo Grimaldi
- U.O.C. Cardiologia-UTIC, Ospedale Miulli, Acquaviva delle Fonti, Italy
| | - Furio Colivicchi
- U.O.C. Cardiologia Clinica e Riabilitativa, Presidio Ospedaliero San Filippo Neri—ASL Roma 1, Rome, Italy
| | - Fabio De Iaco
- S.C. Medicina di Emergenza-Urgenza, Ospedale Maria Vittoria, ASL Città di Torino, Turin, Italy
| | - Fabrizio Oliva
- Unità di Cure Intensive Cardiologiche, Cardiologia 1-Emodinamica, Dipartimento Cardiotoracovascolare ‘A. De Gasperis’, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
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11
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Li Q, Yakhkind A, Alexandrov AW, Alexandrov AV, Anderson CS, Dowlatshahi D, Frontera JA, Hemphill JC, Ganti L, Kellner C, May C, Morotti A, Parry-Jones A, Sheth KN, Steiner T, Ziai W, Goldstein JN, Mayer SA. Code ICH: A Call to Action. Stroke 2024; 55:494-505. [PMID: 38099439 DOI: 10.1161/strokeaha.123.043033] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
Intracerebral hemorrhage is the most serious type of stroke, leading to high rates of severe disability and mortality. Hematoma expansion is an independent predictor of poor functional outcome and is a compelling target for intervention. For decades, randomized trials aimed at decreasing hematoma expansion through single interventions have failed to meet their primary outcomes of statistically significant improvement in neurological outcomes. A wide range of evidence suggests that ultra-early bundled care, with multiple simultaneous interventions in the acute phase, offers the best hope of limiting hematoma expansion and improving functional recovery. Patients with intracerebral hemorrhage who fail to receive early aggressive care have worse outcomes, suggesting that an important treatment opportunity exists. This consensus statement puts forth a call to action to establish a protocol for Code ICH, similar to current strategies used for the management of acute ischemic stroke, through which early intervention, bundled care, and time-based metrics have substantially improved neurological outcomes. Based on current evidence, we advocate for the widespread adoption of an early bundle of care for patients with intracerebral hemorrhage focused on time-based metrics for blood pressure control and emergency reversal of anticoagulation, with the goal of optimizing the benefit of these already widely used interventions. We hope Code ICH will endure as a structural platform for continued innovation, standardization of best practices, and ongoing quality improvement for years to come.
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Affiliation(s)
- Qi Li
- The Second Affiliated Hospital of Anhui Medical University, Hefei, China (Q.L.)
| | | | | | | | - Craig S Anderson
- The George Institute for Global Heath, University of New South Wales, Sydney, Australia (C.S.A.)
| | - Dar Dowlatshahi
- University of Ottawa and Ottawa Hospital Research Institute, Canada (D.D.)
| | | | | | - Latha Ganti
- University of Central Florida College of Medicine, Orlando (L.G.)
| | | | - Casey May
- The Ohio State University College of Pharmacy, Columbus (C.M.)
| | | | | | - Kevin N Sheth
- Yale University School of Medicine, New Haven, CT (K.N.S.)
| | | | - Wendy Ziai
- John Hopkins University School of Medicine, Baltimore, MD (W.Z.)
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12
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Olie RH, Winckers K, Rocca B, Ten Cate H. Oral Anticoagulants Beyond Warfarin. Annu Rev Pharmacol Toxicol 2024; 64:551-575. [PMID: 37758192 DOI: 10.1146/annurev-pharmtox-032823-122811] [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] [Indexed: 10/03/2023]
Abstract
Direct oral anticoagulants (DOACs) have largely replaced vitamin K antagonists, mostly warfarin, for the main indications for oral anticoagulation, prevention and treatment of venous thromboembolism, and prevention of embolic stroke in atrial fibrillation. While DOACs offer practical, fixed-dose anticoagulation in many patients, specific restrictions or contraindications may apply. DOACs are not sufficiently effective in high-thrombotic risk conditions such as antiphospholipid syndrome and mechanical heart valves. Patients with cancer-associated thrombosis may benefit from DOACs, but the bleeding risk, particularly in those with gastrointestinal or urogenital tumors, must be carefully weighed. In patients with frailty, excess body weight, and/or moderate-to-severe chronic kidney disease, DOACs must be cautiously administered and may require laboratory monitoring. Reversal agents have been developed and approved for life-threatening bleeding. In addition, the clinical testing of potentially safer anticoagulants such as factor XI(a) inhibitors is important to further optimize anticoagulant therapy in an increasingly elderly and frail population worldwide.
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Affiliation(s)
- Renske H Olie
- Departments of Internal Medicine (Section of Vascular Medicine) and Biochemistry, Thrombosis Expertise Center, and CARIM School for Cardiovascular Diseases, Maastricht University Medical Center, Maastricht, The Netherlands;
| | - Kristien Winckers
- Departments of Internal Medicine (Section of Vascular Medicine) and Biochemistry, Thrombosis Expertise Center, and CARIM School for Cardiovascular Diseases, Maastricht University Medical Center, Maastricht, The Netherlands;
| | - Bianca Rocca
- Section of Pharmacology, Catholic University School of Medicine, Rome, Italy
- Department of Neurosciences, Psychology, Drug Research and Child Health, University of Florence, Florence, Italy
| | - Hugo Ten Cate
- Departments of Internal Medicine (Section of Vascular Medicine) and Biochemistry, Thrombosis Expertise Center, and CARIM School for Cardiovascular Diseases, Maastricht University Medical Center, Maastricht, The Netherlands;
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
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13
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Lai S, Liu J, Lai CH, Seery S, Hu H, Wang M, Hu H, Xu T. Prognostic variations between 'primary' and 'progressive' muscle-invasive bladder cancer following radical cystectomy: a novel propensity score-based multicenter cohort study. Int J Surg 2024; 110:270-279. [PMID: 37738002 PMCID: PMC10793809 DOI: 10.1097/js9.0000000000000790] [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: 08/01/2023] [Accepted: 09/10/2023] [Indexed: 09/23/2023]
Abstract
OBJECTIVE To assess prognostic differences between primary and progressive muscle-invasive bladder cancer (MIBC) following radical cystectomy. MATERIAL AND METHODS The Surveillance, Epidemiology, and End Results (SEER) database was used to abstract MIBC data following radical cystectomy from 2000 to 2019. Patients were classified as either 'Primary' MIBC (defined as the presentation of muscle-invasive disease at initial diagnosis) or 'Progressive' MIBC (defined as a non-muscle invasive disease that later progressed to MIBC). Baseline characteristics for the two groups were balanced using a propensity score overlap weight (PSOW) technique. Survival differences between the two groups were analyzed using Kaplan-Meier's plots and log-rank tests. Cox's proportional hazard regression was used to assess risk factors associated with overall survival (OS) and cancer-specific survival (CSS). RESULTS Six thousand six hundred thirty-two MIBC patients were identified in the SEER database. Among them, 83.3% ( n =5658) were considered primary MIBC patients, and 16.7% ( n =974) were categorized as progressive MIBC patients. Distribution of baseline covariates, including age, sex, race, T stage, N stage, tumour grade, marital status, and chemotherapy, were well-balanced after PSOWs were applied. After stable PSOW adjustments, Kaplan-Meier survival analysis showed that the CSS for progressive MIBC [hazard ratio (HR)=1.25, 95% confidence interval (CI): 1.12-1.38, P <0.001) was poorer than the primary MIBC group. However, the difference in OS (HR=1.08, 95% CI: 0.99-1.18) was not significant ( P =0.073). Multivariate analysis also suggested that patients with progressive MIBC have significantly poorer CSS (HR=1.24, 95% CI: 1.19-1.38, P <0.001) but not OS (HR=1.08, 95% CI: 0.99-1.18, P =0.089). CONCLUSION CSS for progressive MIBC patients appears worse than for those with primary MIBC. This highlights the need to direct more resources for this patient population and particularly for high-risk cases of non-MIBC, where timely radical surgery will improve patients prognoses.
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Affiliation(s)
- Shicong Lai
- Department of Urology, Peking University People’s Hospital
| | - Jianyong Liu
- Department of Urology, Beijing Hospital; National Center of Gerontology; Institute of Geriatric Medicine, Chinese Academy of Medical Sciences
- Graduate School of Peking Union Medical College and Chinese Academy of Medical Sciences
- Beijing Hospital Continence Center, Beijing, China
| | - Chin-Hui Lai
- Department of Urology, Peking University People’s Hospital
| | - Samuel Seery
- Faculty of Health and Medicine, Division of Health Research, Lancaster University, Lancaster, LA1 4YW, UK
| | - Haopu Hu
- Department of Urology, Peking University People’s Hospital
| | - Mingrui Wang
- Department of Urology, Peking University People’s Hospital
| | - Hao Hu
- Department of Urology, Peking University People’s Hospital
| | - Tao Xu
- Department of Urology, Peking University People’s Hospital
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14
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Fasanya C, Arrillaga A, Caronia C, Rothburd L, Japhe T, Hahn Y, Joseph P, Reci D, Eckardt P. Use of Andexanet Alfa for Factor Xa Inhibitor Reversal in US Verified Trauma Centers: A National Survey. Clin Appl Thromb Hemost 2024; 30:10760296241238013. [PMID: 38494906 PMCID: PMC10946067 DOI: 10.1177/10760296241238013] [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: 11/16/2023] [Revised: 02/14/2024] [Accepted: 02/22/2024] [Indexed: 03/19/2024] Open
Abstract
Direct oral factor Xa inhibitors are replacing vitamin K-dependent antagonists as anticoagulation treatment in many clinical scenarios. Trauma centers are noting an increase in patients presenting on these medications. The 2018 Food and Drug Administration approval of andexanet alfa provides an alternative anticoagulation reversal. Barriers may limit utilization of new medications including a lack of grade 1A evidence supporting the use of prothrombin complex concentrate (PCC) versus andexanet alfa and cost. To evaluate barriers of andexanet alfa utilization by trauma surgeons, a 15-question survey was conducted. There was a 9% completion rate (n = 89). The results revealed 23.5% would choose andexanet alfa as first-line treatment in children, and 25.8% as first-line treatment in adults. The majority of respondents, 64.7% and 67.4%, would use PCC preferentially in children and adults, respectively. Respondents indicated that cost burden was an overriding factor (76.3%); 42.4% cited lack of high-level efficacy data of andexanet alfa for reversal of factor Xa inhibitors. Additional double-blinded multi-institutional randomized controlled trials comparing 4F-PCC and andexanet alfa for factor Xa inhibitor reversal are needed to support efficacy especially with the increased cost associated.
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Affiliation(s)
- Charles Fasanya
- Department of Trauma Surgery/Critical Care, Good Samaritan University Hospital, West Islip, New York, USA
| | - Abenámar Arrillaga
- Department of Trauma Surgery/Critical Care, Good Samaritan University Hospital, West Islip, New York, USA
| | - Catherine Caronia
- Department of Pediatrics, Graduate Medical Education, Good Samaritan University Hospital, West Islip, New York, USA
| | - Lauren Rothburd
- Trauma Services, Good Samaritan University Hospital, West Islip, New York, USA
| | - Tenzing Japhe
- Department of Surgery, New York Institute of Technology College of Osteopathic Medicine, Glen Head, New York, USA
| | - Younghee Hahn
- Department of Surgery, New York Institute of Technology College of Osteopathic Medicine, Glen Head, New York, USA
| | - Paul Joseph
- Department of Surgery, New York Institute of Technology College of Osteopathic Medicine, Glen Head, New York, USA
| | - Dajana Reci
- Department of Surgery, New York Institute of Technology College of Osteopathic Medicine, Glen Head, New York, USA
| | - Patricia Eckardt
- Trauma Services, Nursing Administration, Good Samaritan University Hospital, West Islip, New York, USA
- Barbara H. Hagan School of Nursing and Health Sciences, Molloy University, Rockville Centre, New York, USA
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15
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Heuts S, Ceulemans A, Kuiper GJAJM, Schreiber JU, van Varik BJ, Olie RH, Ten Cate H, Maessen JG, Milojevic M, Maesen B. Optimal management of cardiac surgery patients using direct oral anticoagulants: recommendations for clinical practice. Eur J Cardiothorac Surg 2023; 64:ezad340. [PMID: 37812245 PMCID: PMC10585358 DOI: 10.1093/ejcts/ezad340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 09/26/2023] [Accepted: 10/06/2023] [Indexed: 10/10/2023] Open
Abstract
OBJECTIVES Literature is scarce on the management of patients using direct oral anticoagulants (DOACs) undergoing elective, urgent and emergency surgery. Therefore, we summarize the current evidence and provide literature-based recommendations for the management of patients on DOACs in the perioperative phase. METHODS A general literature review was conducted on the pharmacology of DOACs and for recommendations on the management of cardiac surgical patients on DOACs. Additionally, we performed a systematic review for studies on the use of direct DOAC reversal agents in the emergency cardiac surgical setting. RESULTS When surgery is elective, the DOAC cessation strategy is relatively straightforward and should be adapted to the renal function. The same approach applies to urgent cases, but additional DOAC activity drug level monitoring tests may be useful. In emergency cases, idarucizumab can be safely administered to patients on dabigatran in any of the perioperative phases. However, andexanet alfa, which is not registered for perioperative use, should not be administered in the preoperative phase to reverse the effect of factor Xa inhibitors, as it may induce temporary heparin resistance. Finally, the administration of (activated) prothrombin complex concentrate may be considered in all patients on DOACs, and such concentrates are generally readily available. CONCLUSIONS DOACs offer several advantages over vitamin K antagonists, but care must be taken in patients undergoing cardiac surgery. Although elective and urgent cases can be managed relatively straightforwardly, the management of emergency cases requires particular attention.
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Affiliation(s)
- Samuel Heuts
- Department of Cardiothoracic Surgery, Maastricht University Medical Centre+, Maastricht, Netherlands
- Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands
| | - Angelique Ceulemans
- Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands
- Department of Neurology, Maastricht University Medical Centre+, Maastricht, Netherlands
| | - Gerhardus J A J M Kuiper
- Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands
- Department of Anaesthesiology and Pain Treatment, Maastricht University Medical Centre+, Maastricht, Netherlands
| | - Jan U Schreiber
- Department of Anaesthesiology and Pain Treatment, Maastricht University Medical Centre+, Maastricht, Netherlands
| | | | - Renske H Olie
- Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands
- Thrombosis Expertise Centre, Maastricht University Medical Centre+, Maastricht, Netherlands
- Department of Internal Medicine, Section Vascular Medicine, Maastricht University Medical Centre+, Maastricht, Netherlands
| | - Hugo Ten Cate
- Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands
- Thrombosis Expertise Centre, Maastricht University Medical Centre+, Maastricht, Netherlands
- Department of Internal Medicine, Section Vascular Medicine, Maastricht University Medical Centre+, Maastricht, Netherlands
| | - Jos G Maessen
- Department of Cardiothoracic Surgery, Maastricht University Medical Centre+, Maastricht, Netherlands
- Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands
| | - Milan Milojevic
- Department of Cardiac Surgery and Cardiovascular Research, Dedinje Cardiovascular Institute, Belgrade, Serbia
| | - Bart Maesen
- Department of Cardiothoracic Surgery, Maastricht University Medical Centre+, Maastricht, Netherlands
- Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands
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16
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Orban JE, Ruckel C, Harlan S. Concomitant andexanet alfa and 4 F-PCC for Factor Xa inhibitor associated intracranial hemorrhage. Clin Neurol Neurosurg 2023; 233:107908. [PMID: 37515854 DOI: 10.1016/j.clineuro.2023.107908] [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: 06/03/2023] [Revised: 07/15/2023] [Accepted: 07/17/2023] [Indexed: 07/31/2023]
Abstract
Andexanet alfa is the only FDA approved drug for acute reversal of life-threatening bleeding associated with oral factor Xa inhibitor agents. The case series investigates clinical outcomes of four patients receiving concomitant Andexanet alfa and Four Factor Prothrombin Concentrate Complex (4 F-PCC) for acute reversal of intracranial hemorrhage. Following administration, effective hemostasis was achieved in two patients (50%) and one patient (25%) experienced an acute ischemic stroke. Two patients (50%) expired prior to discharge without achieving hemostasis. This case series serves to further expand the limited data on the concomitant administration of Andexanet alfa and 4 F-PCC.
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Affiliation(s)
- James E Orban
- Lexington Medical Center, 2720 Sunset Blvd, West Columbia, SC, 29169, USA.
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17
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Backus B, Beyer-Westendorf J, Body R, Lindner T, Möckel M, Sehgal V, Parry-Jones A, Seiffge D, Gibler B. Management of major bleeding for anticoagulated patients in the Emergency Department: an European experts consensus statement. Eur J Emerg Med 2023; 30:315-323. [PMID: 37427548 DOI: 10.1097/mej.0000000000001049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/11/2023]
Abstract
An increasing number of patients presenting to the emergency department (ED) with life-threatening bleeding are using oral anticoagulants, such as warfarin, Factor IIa and Factor Xa inhibitors. Achieving rapid and controlled haemostasis is critically important to save the patient's life. This multidisciplinary consensus paper provides a systematic and pragmatic approach to the management of anticoagulated patients with severe bleeding at the ED. Repletion and reversal management of the specific anticoagulants is described in detail. For patients on vitamin K antagonists, the administration of vitamin K and repletion of clotting factors with four-factor prothrombin complex concentrate provides real-time ability to stop the bleeding. For patients using a direct oral anticoagulant, specific antidotes are necessary to reverse the anticoagulative effect. For patients receiving the thrombin inhibitor dabigatran, treatment with idarucizamab has been demonstrated to reverse the hypocoagulable state. For patients receiving a factor Xa inhibitor (apixaban or rivaroxaban), andexanet alfa is the indicated antidote in patients with major bleeding. Lastly, specific treatment strategies are discussed in patients using anticoagulants with major traumatic bleeding, intracranial haemorrhage or gastrointestinal bleeding.
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Affiliation(s)
- Barbra Backus
- Emergency Department, Franciscus Gasthuis and Vlietland, Rotterdam
- Emergency Department, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands
| | | | - Rick Body
- Division of Cardiovascular Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Tobias Lindner
- Emergency and Acute Medicine, Campus Virchow, Charité - Universitätsmedizin, Berlin, Germany
| | - Martin Möckel
- Emergency and Acute Medicine, Campus Virchow, Charité - Universitätsmedizin, Berlin, Germany
| | - Vinay Sehgal
- Department of Gastroenterology, University College London Hospital, London
| | - Adrian Parry-Jones
- Division of Cardiovascular Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
- Geoffrey Jefferson Brain Research Centre, Manchester Academic Health Science Centre, Northern Care Alliance NHS Foundation Trust & University of Manchester, Manchester
- Manchester Centre for Clinical Neurosciences, Northern Care Alliance NHS Foundation Trust, Salford, UK
| | - David Seiffge
- Department of Neurology, Inselspital University Hospital Bern, University of Bern, Bern, Switzerland
| | - Brian Gibler
- University of Cincinnati College of Medicine President, Department of Emergency Medicine, Cincinnati, Ohio, USA
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18
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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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19
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Singer AJ, Concha M, Williams J, Brown CS, Fernandes R, Thode HC, Kirchman M, Rabinstein AA. Treatment of Factor-Xa Inhibitor-associated Bleeding with Andexanet Alfa or 4 Factor PCC: A Multicenter Feasibility Retrospective Study. West J Emerg Med 2023; 24:939-949. [PMID: 37788035 PMCID: PMC10527834 DOI: 10.5811/westjem.60587] [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: 03/31/2023] [Revised: 07/06/2023] [Accepted: 07/20/2023] [Indexed: 10/04/2023] Open
Abstract
Background: There are no randomized trials comparing andexanet alfa and 4 factor prothrombin complex concentrate (4F-PCC) for the treatment of factor Xa inhibitor (FXa-I)-associated bleeds, and observational studies lack important patient characteristics. We pursued this study to demonstrate the feasibility of acquiring relevant patient characteristics from electronic health records. Secondarily, we explored outcomes in patients with life-threatening FXa-I associated bleeds after adjusting for these variables. Methods: We conducted a multicenter, chart review of 100 consecutive adult patients with FXa-I associated intracerebral hemorrhage (50) or gastrointestinal bleeding (50) treated with andexanet alfa or 4F-PCC. We collected demographic, clinical, laboratory, and imaging data including time from last factor FXa-I dose and bleed onset. Results: Mean (SD) age was 75 (12) years; 34% were female. Estimated time from last FXa-I dose to bleed onset was present in most cases (76%), and patients treated with andexanet alfa and 4F-PCC were similar in baseline characteristics. Hemostatic efficacy was excellent/good in 88% and 76% of patients treated with andexanet alfa and 4F-PCC, respectively (P = 0.29). Rates of thrombotic events within 90 days were 14% and 16% in andexanet alfa and 4F-PCC patients, respectively (P = 0.80). Survival to hospital discharge was 92% and 76% in andexanet alfa and 4F-PCC patients, respectively (P = 0.25). Inclusion of an exploratory propensity score and treatment in a logistic regression model resulted in an odds ratio in favor of andexanet alfa of 2.01 (95% confidence interval 0.67-6.06) for excellent/good hemostatic efficacy, although the difference was not statistically significant. Conclusion: Important patient characteristics are often documented supporting the feasibility of a large observational study comparing real-life outcomes in patients with FXa-I-associated bleeds treated with andexanet alfa or 4F-PCC. The small sample size in the current study precluded definitive conclusions regarding the safety and efficacy of andexanet alfa or 4F-PCC in FXa-I-associated bleeds.
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Affiliation(s)
- Adam J Singer
- Renaissance School of Medicine at Stony Brook University, Department of Emergency Medicine, Stony Brook, New York,
| | - Mauricio Concha
- Sarasota Memorial Hospital, Department of Neuroscience, Sarasota, Florida
| | - James Williams
- Meritus Health, Department of Emergency Medicine, Hagerstown, Maryland
| | - Caitlin S Brown
- Mayo Clinic-Rochester, Department of Pharmacy, Rochester, Minnesota
| | - Rafael Fernandes
- Renaissance School of Medicine at Stony Brook University, Department of Emergency Medicine, Stony Brook, New York
| | - Henry C Thode
- Renaissance School of Medicine at Stony Brook University, Department of Emergency Medicine, Stony Brook, New York
| | - Marylin Kirchman
- Sarasota Memorial Hospital, Department of Neuroscience, Sarasota, Florida
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20
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Malik GMA, Kumar S, Samiullah. Comment on "Emergent external ventricular drain placement in patients with factor Xa inhibitor-associated intracerebral hemorrhage after reversal with andexanet alfa". Clin Neurol Neurosurg 2023; 232:107858. [PMID: 37429210 DOI: 10.1016/j.clineuro.2023.107858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 06/24/2023] [Indexed: 07/12/2023]
Affiliation(s)
- Ghulam Mustafa Ali Malik
- Dow International Medical College, Block-16 Gulshan-e-Iqbal, Hassan Centre, Apartment Number C-8, Karachi, Pakistan.
| | - Satesh Kumar
- Shaheed Mohtarma Benazir Bhutto Medical College Lyari, Karachi, Pakistan
| | - Samiullah
- Shaheed Mohtarma Benazir Bhutto Medical College Lyari, Karachi, Pakistan
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21
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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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22
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Angelillo-Scherrer A, Casini A, Studt JD, Gerber B, Alberio LA, Fontana P. Recommendations for the use of andexanet alfa in the management of bleeding in patients on oral factor Xa inhibitors in Switzerland: Guideline from the Working Party Hemostasis of the Swiss Society of Hematology. Swiss Med Wkly 2023; 153:40113. [PMID: 37499160 DOI: 10.57187/smw.2023.40113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/29/2023] Open
Abstract
Anticoagulants are essential in preventing and treating thrombosis. Unfortunately, their use is accompanied by an enhanced risk of bleeding. Since the introduction of direct oral anticoagulants (DOACs), the risk of major bleeding has been reduced but not eliminated. Major bleeding events related to the use of factor Xa inhibitors can be challenging to manage. In recent years, four-factor prothrombin complex concentrates have been used in patients with severe bleeding taking oral direct factor Xa inhibitors (apixaban, edoxaban and rivaroxaban). Andexanet alfa (OndexxyaTM, AstraZeneca AG) is a specially designed recombinant version of human factor Xa that acts as a decoy receptor to reverse the effects of factor Xa inhibitors. Since 2 December 2020, andexanet alfa has been used in Switzerland for adult patients receiving apixaban or rivaroxaban when reversal of anticoagulation is required because of life-threatening or uncontrolled bleeding. However, the use of andexanet alfa remains a challenge owing to its cost, the reported thrombotic complications and the fact that its efficacy mainly relates to intracranial haemorrhage. Moreover, the use of nonspecific reversal agents together with andexanet alfa is controversial. The present recommendations on the use of andexanet alfa in the management of bleeding in patients on factor Xa inhibitors in Switzerland were developed by a group of Swiss experts from the Working Party Hemostasis of the Swiss Society of Hematology. These recommendations aim to provide support to clinicians in their decision-making in the management of patients with major bleeding receiving factor Xa inhibitors.
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Affiliation(s)
- Anne Angelillo-Scherrer
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Alessandro Casini
- Division of Angiology and Hemostasis, Geneva University Hospital, Geneva, Switzerland
| | - Jan-Dirk Studt
- University Clinic of Hematology, Zurich University Hospital, Zurich, Switzerland
| | - Bernhard Gerber
- Clinic of Hematology, Oncology Institute of Southern Switzerland, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
| | - Lorenzo A Alberio
- Service and Central Laboratory of Hematology, Lausanne University Hospital, Lausanne, Switzerland
| | - Pierre Fontana
- Division of Angiology and Hemostasis, Geneva University Hospital, Geneva, Switzerland
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23
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Kubica J, Adamski P, Gajda R, Gąsior M, Gierlotka M, Gil R, Jaguszewski M, Kubica A, Kuliczkowski W, Kurek K, Ładny JR, Michalski P, Navarese EP, Niezgoda P, Ostrowska M, Tycińska A. Andexanet alfa - Recommendations for clinical use. Multidisciplinary experts' standpoint. Cardiol J 2023; 30:502-505. [PMID: 37401419 PMCID: PMC10508081 DOI: 10.5603/cj.a2023.0043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 06/15/2023] [Accepted: 06/15/2023] [Indexed: 07/05/2023] Open
Affiliation(s)
- Jacek Kubica
- Department of Cardiology and Internal Medicine, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland.
| | - Piotr Adamski
- Department of Cardiology and Internal Medicine, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | | | - Mariusz Gąsior
- 3rd Department of Cardiology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland
| | - Marek Gierlotka
- Department of Cardiology, Institute of Medical Sciences, University of Opole, Poland
| | - Robert Gil
- Mossakowski Medical Research Institute, Polish Academy of Science, Warsaw, Poland
| | | | - Aldona Kubica
- Department of Cardiac Rehabilitation and Health Promotion, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | | | - Krzysztof Kurek
- Department of Gastroenterology and Internal Medicine, Medical University of Bialystok, Poland
| | - Jerzy Robert Ładny
- Department of Emergency Medicine, Medical University of Bialystok, Poland
| | - Piotr Michalski
- Department of Cardiac Rehabilitation and Health Promotion, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Eliano Pio Navarese
- Department of Cardiology and Internal Medicine, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Piotr Niezgoda
- Department of Cardiology and Internal Medicine, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Małgorzata Ostrowska
- Department of Cardiology and Internal Medicine, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
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24
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Heubner L, Vicent O, Beyer-Westendorf J, Spieth PM. Bleeding management in patients with direct oral anticoagulants. Minerva Anestesiol 2023; 89:707-715. [PMID: 37079285 DOI: 10.23736/s0375-9393.23.17230-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/21/2023]
Abstract
Bleeding events in patients under direct oral anticoagulation (DOAC) can be life-threating but are commonly not related to drug overdose. However, a relevant DOAC plasma concentration impairs the hemostasis and should therefore be ruled out immediately after hospital admission. The effect of DOAC is typically not visible in standard coagulation tests such as activated partial thrombin time or thromboplastin time. Specific anti-Xa or anti-IIa assays allow a specific drug monitoring, but they are too time-consuming in critical bleeding events and typically not available 24 h/7 d in routine care. Recent advantages in point-of-care (POC) testing might improve patient care by early exclusion of relevant DOAC levels, but sufficient validation is still lacking. POC urine analysis help to exclude DOAC in emergency patients, but does not provide a quantitative information about plasma concentration. POC viscoelastic testing (VET) can determine the DOAC effect on clotting time and helps further to reveal other concomitant bleeding disorders in emergency, e.g., factor deficiency or hyperfibrinolysis. If a relevant plasma concentration of the DOAC is assumed or was proven by either laboratory assays or POC testing, restoration of factor IIa or factor IIa activity is key for effective hemostasis. Limited evidence suggests that specific reversals for DOAC, e.g., idarucizumab for dabigatran and andexanet alfa for apixaban or rivaroxaban, might be superior to increasing thrombin generation by administration of prothrombin complex concentrates. To determinate, if DOAC reversal is indicated or not, time from last intake, anti-Xa/dTT values or results from POC tests can be considered. This experts' opinion provides a feasible decision algorithm for clinical practice.
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Affiliation(s)
- Lars Heubner
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden (TU Dresden), Dresden, Germany -
| | - Oliver Vicent
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden (TU Dresden), Dresden, Germany
| | - Jan Beyer-Westendorf
- Unit of Thrombosis Research, Division of Hematology and Hemostasis, Department of Medicine I, University Hospital Carl Gustav Carus, Technische Universität Dresden (TU Dresden), Dresden, Germany
| | - Peter M Spieth
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden (TU Dresden), Dresden, Germany
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25
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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: 0] [Impact Index Per Article: 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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26
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De Marco F, Valli G, Ancona C, Ruggieri MP. Management of bleeding in patients on direct oral anticoagulants in emergency department: where we are and where we are going. Eur Heart J Suppl 2023; 25:C15-C19. [PMID: 37125272 PMCID: PMC10132614 DOI: 10.1093/eurheartjsupp/suad004] [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] [Indexed: 05/02/2023]
Abstract
Many patients who access in the emergency department for acute bleeding are on anticoagulants; before specific reversal agents were developed, bleeding on anticoagulants was burdened with a substantial increase in morbidity and mortality. Clinical trials demonstrated favourable risk-benefit profiles of direct-acting oral anticoagulants compared with vitamin K antagonists in patients with atrial fibrillation and compared with low molecular weight heparin in patients treated and prevented from venous thromboembolism. Even if they drastically reduced some types of bleeding, particularly intracranial haemorrhage, they have not completely eliminated this risk. The arrival of a patient with active bleeding in the emergency department is always a critical scenario that involves resources and costs. In critical setting, the diagnosis and treatment of bleeding should occurred simultaneously. Understanding the pathophysiological mechanisms that occur during bleeding is essential for establish the most appropriate therapies and improve the standard of care of the haemorrhagic patients.
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Affiliation(s)
| | - Gabriele Valli
- Department of Emergency Medicine, San Giovanni Addolorata Hospital, via dell'Amba Aradam, 8 00184 Rome, Italy
| | - Carlo Ancona
- Department of Emergency Medicine, San Giovanni Addolorata Hospital, via dell'Amba Aradam, 8 00184 Rome, Italy
| | - Maria Pia Ruggieri
- Department of Emergency Medicine, San Giovanni Addolorata Hospital, via dell'Amba Aradam, 8 00184 Rome, Italy
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27
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Zghaib T, Allison JD, Barrett C, Arkles J, D'Souza B, Luebbert J, Garcia F, Heist EK, Tzou W, Callans D, Marchlinski FE, Frankel DS. Multicenter experience with andexanet alfa for refractory pericardial bleeding during catheter ablation of atrial fibrillation. J Cardiovasc Electrophysiol 2023; 34:593-597. [PMID: 36598431 DOI: 10.1111/jce.15801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 12/05/2022] [Accepted: 12/28/2022] [Indexed: 01/05/2023]
Abstract
INTRODUCTION Pericardial bleeding is a rare but life-threatening complication of atrial fibrillation (AF) ablation. Patients taking uninterrupted oral anticoagulation (AC) may be at increased risk for refractory bleeding despite pericardiocentesis and administration of protamine. In such cases, andexanet alfa can be given to reverse rivaroxaban or apixaban. In this study, we aim to describe the rate of acute hemostasis and thromboembolic complications with andexanet for refractory pericardial bleeding during AF ablation. METHODS AND RESULTS In this multicenter, case series, participating centers identified patients who received a dose of apixaban or rivaroxaban within 24 h of AF ablation, developed refractory pericardial bleeding during the procedure despite pericardiocentesis and administration of protamine and received andexanet. Eleven patients met inclusion criteria, with mean age of 73.5 ± 5.3 years and median CHA2 DS2 -VASc score 4 [3-5]. All patients received protamine and pericardiocentesis, and 9 (82%) received blood products. All patients received a bolus of andexanet followed, in all but one, by a 2-h infusion. Acute hemostasis was achieved in eight patients (73%) while three required emergent surgery. One patient (9%) experienced acute ST-elevation myocardial infarction after receiving andexanet. Therapeutic AC was restarted after a mean of 2.2 ± 1.9 days and oral AC was restarted after a mean of 2.9 ± 1.6 days, with no recurrent bleeding. CONCLUSION In patients on uninterrupted apixaban or rivaroxaban, who develop refractory pericardial bleeding during AF ablation, andexanet can achieve hemostasis thereby avoiding the need for emergent surgery. However, there is a risk of thromboembolism following administration.
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Affiliation(s)
- Tarek Zghaib
- Division of Cardiovascular Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - John D Allison
- Cardiac Arrhythmia Unit, Heart Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Christopher Barrett
- Division of Cardiovascular Medicine, Section of Electrophysiology, School of Medicine, University of Colorado, Aurora, Colorado, USA
| | - Jeffrey Arkles
- Division of Cardiovascular Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Benjamin D'Souza
- Division of Cardiovascular Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jeffrey Luebbert
- Division of Cardiovascular Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Fermin Garcia
- Division of Cardiovascular Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - E Kevin Heist
- Cardiac Arrhythmia Unit, Heart Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Wendy Tzou
- Division of Cardiovascular Medicine, Section of Electrophysiology, School of Medicine, University of Colorado, Aurora, Colorado, USA
| | - David Callans
- Division of Cardiovascular Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Francis E Marchlinski
- Division of Cardiovascular Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David S Frankel
- Division of Cardiovascular Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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28
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Coleman CI, Costa OS, Connolly SJ, Sharma M, Beyer-Westendorf J, Christoph-Schubel MJ, Lovelace B. Response to the Letter by Spurling and Colleagues. Crit Care 2023; 27:65. [PMID: 36804034 PMCID: PMC9940403 DOI: 10.1186/s13054-023-04352-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Accepted: 02/08/2023] [Indexed: 02/22/2023] Open
Affiliation(s)
- Craig I. Coleman
- grid.63054.340000 0001 0860 4915Department of Pharmacy Practice, University of Connecticut School of Pharmacy, 69 North Eagleville Road, Unit 3092, Storrs, CT 06269 USA ,grid.277313.30000 0001 0626 2712Evidence-Based Practice Center, Hartford Hospital, Hartford, CT USA
| | - Olivia S. Costa
- grid.63054.340000 0001 0860 4915Department of Pharmacy Practice, University of Connecticut School of Pharmacy, 69 North Eagleville Road, Unit 3092, Storrs, CT 06269 USA ,grid.277313.30000 0001 0626 2712Evidence-Based Practice Center, Hartford Hospital, Hartford, CT USA
| | - Stuart J. Connolly
- grid.25073.330000 0004 1936 8227McMaster University, Hamilton, ON Canada ,grid.415102.30000 0004 0545 1978Population Health Research Institute, Hamilton, ON Canada
| | - Mukul Sharma
- grid.25073.330000 0004 1936 8227McMaster University, Hamilton, ON Canada ,grid.415102.30000 0004 0545 1978Population Health Research Institute, Hamilton, ON Canada
| | - Jan Beyer-Westendorf
- grid.4488.00000 0001 2111 7257Thrombosis and Anticoagulation Service, Division Hematology and Hemostaseology, Department of Medicine I, Dresden University Hospital, Dresden, Germany
| | - Mary J. Christoph-Schubel
- grid.418152.b0000 0004 0543 9493Department of Global Medical and Payer Evidence, AstraZeneca Pharmaceuticals, South San Francisco, CA USA
| | - Belinda Lovelace
- grid.418152.b0000 0004 0543 9493Department of Health Economics and Payer Evidence, AstraZeneca Pharmaceuticals, Gaithersburg, MD USA
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29
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Beyer-Westendorf J, Köhler C. Direct Oral Anticoagulants: Laboratory Challenges and Antidotes. Hamostaseologie 2023; 43:37-43. [PMID: 36807818 DOI: 10.1055/a-1987-3559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023] Open
Abstract
The use of direct oral anticoagulants (DOACs) is increasing in patients needing treatment of venous thromboembolism (VTE) and stroke prevention in atrial fibrillation (SPAF). This is due to the net clinical benefit in comparison to vitamin K antagonists (VKAs). The rise in DOAC use is accompanied by a remarkable reduction in heparin and VKA prescriptions. However, this rapid change in anticoagulation patterns brought new challenges to patients, prescribers, laboratories, and emergency physicians. Patients have new liberties concerning nutritional habits and comedication and no longer need frequent monitoring or dose adjustments. Still, they have to comprehend that DOACs are potent anticoagulants that may cause or contribute to bleeding. Challenges for the prescriber include decision pathways for choosing the right anticoagulant and dosage for a specific patient and to change bridging practice in case of invasive procedures. Laboratory personnel are challenged by DOAC due to limited 24/7 availability of specific DOAC quantification tests and by the impact of DOAC on routine coagulation assays and thrombophilia tests. Challenges for the emergency physician result from the increasing age of DOAC anticoagulated patients, the difficulties to establish last intake of DOAC type and dosage, to interpret coagulation test results in emergency situations, and to make decisions for or against DOAC reversal strategies in acute bleeding or urgent surgery. In conclusion, although DOACs make long-term anticoagulation safer and more convenient for patients, DOACs pose challenge to all healthcare providers involved in anticoagulation decisions. The key to correct patient management and optimal outcome therefore lies in education.
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Affiliation(s)
- Jan Beyer-Westendorf
- Department of Medicine I, Universitätsklinikum "Carl Gustav Carus," Dresden, Germany
| | - Christina Köhler
- Department of Medicine I, Universitätsklinikum "Carl Gustav Carus," Dresden, Germany
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30
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Spurling J, Glowacki N, McDowell M. In Reply: Costa et al. Crit Care 2022; 26:407. [PMID: 36585692 PMCID: PMC9805081 DOI: 10.1186/s13054-022-04254-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Accepted: 11/23/2022] [Indexed: 12/31/2022] Open
Affiliation(s)
- Jordan Spurling
- grid.185648.60000 0001 2175 0319University of Illinois at Chicago, Chicago, USA
| | | | - Marc McDowell
- grid.185648.60000 0001 2175 0319University of Illinois at Chicago, Chicago, USA
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31
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Lipski M, Pasciolla S, Wojcik K, Jankowitz B, A Igneri L. Comparison of 4-factor prothrombin complex concentrate and andexanet alfa for reversal of apixaban and rivaroxaban in the setting of intracranial hemorrhage. J Thromb Thrombolysis 2022; 55:519-526. [PMID: 36566473 DOI: 10.1007/s11239-022-02752-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/05/2022] [Indexed: 12/26/2022]
Abstract
The purpose of this study was to evaluate and compare clinical outcomes in patients who experienced intracranial hemorrhage (ICH) while taking apixaban or rivaroxaban and were reversed with four-factor prothrombin complex concentrates (4F-PCC) or andexanet alfa (AA). This retrospective cohort included adult patients that received 4F-PCC or AA for the initial management of an apixaban- or rivaroxaban-associated ICH. A primary outcome of excellent or good hemostatic efficacy at 12 h post-reversal was assessed. Secondary outcomes evaluated were change in hematoma volume size at 12 h, functional status at discharge, need for surgical intervention or additional hemostatic agents post-reversal, new thrombotic event within 28 days, 28-day all-cause mortality, discharge disposition, and hospital and intensive care unit lengths of stay. A total of 70 patients were included (4F-PCC, n = 47; AA, n = 23). For the primary outcome analysis, 21 patients were included in the 4F-PCC group and 12 in the AA group. The rate of effective hemostasis was similar between the 4F-PCC and AA groups (66.7% vs 75%, p = 0.62). There were no statistically significant differences between the groups for secondary outcomes, including 28-day mortality (40.4% vs 39.1%, p = 0.92) and thrombotic complications within 28 days of reversal (17.0% vs 21.7%, p = 0.63). In patients who experienced an ICH while taking apixaban or rivaroxaban, 4F-PCC and AA were found to have similar rates of excellent or good hemostatic efficacy.
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Affiliation(s)
- Michelle Lipski
- Department of Pharmacy, University of Pittsburgh Medical Center Hamot, Erie, PA, 16506, USA.
| | - Stacy Pasciolla
- Department of Pharmacy, Philadelphia College of Pharmacy, Saint Joseph's University, Philadelphia, PA, USA.,Department of Pharmacy, Cooper University Health Care, Camden, NJ, USA
| | - Kevin Wojcik
- Department of Neurosurgery, Philadelphia College of Osteopathic Medicine, Philadelphia, PA, USA.,Department of Neurosurgery, Perelman School of Medicine at the Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Brian Jankowitz
- Department of Neurosurgery, Perelman School of Medicine at the Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Lauren A Igneri
- Department of Pharmacy, Cooper University Health Care, Camden, NJ, USA
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