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Demchuk AM, Yue P, Zotova E, Nakamya J, Xu L, Milling TJ, Ohara T, Goldstein JN, Middeldorp S, Verhamme P, Lopez-Sendon JL, Conley PB, Curnutte JT, Eikelboom JW, Crowther M, Connolly SJ. Hemostatic Efficacy and Anti-FXa (Factor Xa) Reversal With Andexanet Alfa in Intracranial Hemorrhage: ANNEXA-4 Substudy. Stroke 2021; 52:2096-2105. [PMID: 33966491 PMCID: PMC8140631 DOI: 10.1161/strokeaha.120.030565] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 01/29/2021] [Accepted: 03/11/2021] [Indexed: 12/12/2022]
Abstract
Background and Purpose Andexanet alfa is a recombinant modified human FXa (factor Xa) developed to reverse FXa inhibition from anticoagulants. Hemostatic efficacy and reversal of anti-FXa activity with andexanet were assessed in patients from the ANNEXA-4 study (Andexanet Alfa, a Novel Antidote to the Anticoagulation Effects of FXa Inhibitors) with intracranial hemorrhage (ICrH). Methods ANNEXA-4 was a single-arm study evaluating andexanet in patients presenting with major bleeding ≤18 hours after taking an FXa inhibitor. Patients received a bolus plus 2-hour infusion of andexanet. Brain imaging in patients with ICrH was performed at baseline and at 1 and 12 hours postandexanet infusion. Coprimary efficacy outcomes were change in anti-FXa activity and hemostatic efficacy at 12 hours (excellent/good efficacy defined as ≤35% increase in hemorrhage volume/thickness). Safety outcomes included occurrence of thrombotic events and death at 30 days. Results A total of 227 patients with ICrH were included in the safety population (51.5% male; mean age 79.3 years) and 171 in the efficacy population (99 spontaneous and 72 traumatic bleeds). In efficacy evaluable patients, excellent/good hemostasis 12 hours postandexanet occurred in 77 out of 98 (78.6%) and in 58 out of 70 (82.9%) patients with spontaneous and traumatic bleeding, respectively. In the subanalysis by FXa inhibitor treatment group in the efficacy population, median of percent change in anti-FXa from baseline to nadir showed a decrease of 93.8% for apixaban-treated patients (n=99) and by 92.6% for rivaroxaban-treated patients (n=59). Within 30 days, death occurred in 34 out of 227 (15.0%) patients and thrombotic events occurred in 21 out of 227 (9.3%) patients (safety population). Conclusions Andexanet reduced anti-FXa activity in FXa inhibitor-treated patients with ICrH, with a high rate of hemostatic efficacy. Andexanet may substantially benefit patients with ICrH, the most serious complication of anticoagulation. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT02329327.
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Affiliation(s)
- Andrew M. Demchuk
- Departments of Clinical Neurosciences and Radiology, Cumming School of Medicine, University of Calgary, AB, Canada (A.M.D.)
| | - Patrick Yue
- Portola Pharmaceuticals, Inc, now Alexion Pharmaceuticals, Inc, South San Francisco, CA (P.Y., P.B.C., J.T.C.)
| | - Elena Zotova
- Department of Medicine, McMaster University, Hamilton, ON, Canada (E.Z., J.N., L.X., J.W.E., M.C., S.J.C.)
| | - Juliet Nakamya
- Department of Medicine, McMaster University, Hamilton, ON, Canada (E.Z., J.N., L.X., J.W.E., M.C., S.J.C.)
| | - Lizhen Xu
- Department of Medicine, McMaster University, Hamilton, ON, Canada (E.Z., J.N., L.X., J.W.E., M.C., S.J.C.)
| | - Truman J. Milling
- Department of Neurology, Seton Dell Medical School Stroke Institute, Austin, TX (T.J.M.)
| | - Tomoyuki Ohara
- Department of Neurology, Kyoto Prefectural University of Medicine, Japan (T.O.)
| | - Joshua N. Goldstein
- Department of Emergency Medicine, Massachusetts General Hospital, Boston (J.N.G.)
| | - Saskia Middeldorp
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Meibergdreef, the Netherlands (S.M.)
| | - Peter Verhamme
- Center for Molecular and Vascular Biology, University of Leuven, Belgium (P.V.)
| | - Jose Luis Lopez-Sendon
- Department of Cardiology, Hospital Universitario La Paz, IdiPaz, Universidad Autonoma de Madrid, Spain (J.L.L.-S.)
| | - Pamela B. Conley
- Portola Pharmaceuticals, Inc, now Alexion Pharmaceuticals, Inc, South San Francisco, CA (P.Y., P.B.C., J.T.C.)
| | - John T. Curnutte
- Portola Pharmaceuticals, Inc, now Alexion Pharmaceuticals, Inc, South San Francisco, CA (P.Y., P.B.C., J.T.C.)
| | - John W. Eikelboom
- Department of Medicine, McMaster University, Hamilton, ON, Canada (E.Z., J.N., L.X., J.W.E., M.C., S.J.C.)
| | - Mark Crowther
- Department of Medicine, McMaster University, Hamilton, ON, Canada (E.Z., J.N., L.X., J.W.E., M.C., S.J.C.)
| | - Stuart J. Connolly
- Department of Medicine, McMaster University, Hamilton, ON, Canada (E.Z., J.N., L.X., J.W.E., M.C., S.J.C.)
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