Andexanet alfa for reversal of rivaroxaban in a child with intracranial hemorrhage

Abstract

Direct oral anticoagulants (DOACs), including direct factor Xa (FXa) inhibitors, have become the preferred treatment for thrombosis in adults due to their efficacy, safety, and convenience. Recent studies show promising results for rivaroxaban and dabigatran use in children [1][2][3][4] ; there were no major bleeding events in the rivaroxaban phase 3 pediatric clinical trial and the rate of clinically relevant nonmajor bleeding was 3%. 2 Dabigatran has been FDA approved for pediatrics while rivaroxaban has been submitted for review, and trials are ongoing for other agents. [5][6][7][8][9][10] The use of DOACs for children with thrombosis is therefore anticipated to increase.

How I treat pediatric venous thromboembolism in the DOAC era

“… 65 , 66 , 67 There are only 2 published case reports of using idarucizumab and andexanet-α for children, for overdose and bleeding reversal. 68 , 69 Interestingly, a recent survey of pediatric hematologists assessing preferences for reversal of bleeding associated with DOACs reported prothrombin complex concentrates as the preferred option. 70 In case of a DOAC overdose within 2 to 4 hours, gastric lavage with activated charcoal is suggested.…”

Practical Considerations for Use of Direct Oral Anticoagulants in Children

“…Andexanet alfa works as an inactive recombinant human factor Xa to compete with active factor Xa binding to apixaban and rivaroxaban and is approved for reversal in adults on rivaroxaban or apixaban with life threatening bleeding (42). Published pediatric data is limited to a case report of a 4-year-old, 20 kg female who received andexanet alfa due to an intracranial hemorrhage while taking rivaroxaban without adverse effects (43).…”