Article Figures & Data
Figures
- Figure 1
Algorithm for the reversal of specific anticoagulants, including direct thrombin inhibitors, direct factor Xa inhibitors, warfarin and heparin. FFP, fresh frozen plasma; 4F-PCC,four factor prothrombin complex concentrate;ICH, intracerebral haemorrhage; INR, internationalnormalised ratio; IU, international unit; IV,intravenous; LMWH, low-molecular weight heparin; PCC,prothrombin complex concentrate.
Tables
- Table 1
Direct-acting oral anticoagulants (DOACs) and reversal
DOAC Brand name Mechanism of action Time to onset t1/2 Reversal Dabigatran Pradaxa Direct thrombin inhibitor 0.5–2 hour 15 hours Idarucizumab Rivaroxaban Xarelto Factor Xa inhibitor 2–4 hour 6–12 hour 3F- and 4F-PCC, andexanet alfa Apixaban Eliquis 1–2 hour Edoxaban Savaysa, Lixiana 1–2 hour Andexanet alfa Betrixaban Bevyxxa 3–4 hour 24 hours - Table 2
Anticoagulant reversal agents and their pharmacokinetics
Anticoagulant reversal Brand name Time to reverse coagulopathy t1/2 Terminal elimination t1/2 Idarucizumab Praxbind Minutes 47 m 10 hours Prothrombin complex concentrate Kcentra 40 min factor dependent factor dependent Fresh frozen plasma … >24 hour Andexanet alfa Andexxa Minutes 1 hour 5–7 hour - Table 3
Summary of trials for anticoagulant reversal and haemorrhage treatment
Trial Anticoagulant Anticoagulant reversal Primary endpoint Results INCH25 VKA PCC, FFP Percentage of patients with INR <1.3 within 3 hours of treatment PCC (vs FFP) had a higher rate of INR reversal UPRATE42–44 Rivaroxaban, apixaban 4F-PCC Haemostasis rate 4F-PCC reverses apixaban and rivaroxaban associated bleeding REVERSE-AD43 Dabigatran Idarucizumab Percentage reversal at 4 hours Idarucizumab reverses the effect of dabigatran for most patients (93%) within minutes ANNEXA-444 Rivaroxaban, apixaban Andexanet alfa Change in anti-Xa activity at 12 hours 80% of those with DOAC associated ICH achieved excellent or good haemostasis 12 hours after andexanet alfa SPOTLIGHT and STOP-IT46 … rFVIIa Parenchymal ICH volume expansion on head CT at 24 hours rFVIIa does not improve radiographic findings DOAC, direct-acting oral anticoagulant; FFP, fresh frozen plasma; ICH, intracerebral haemorrhage; INR, international normalised ratio; PCC, prothrombin complex concentrate; VKA, vitamin K antagonist.
