What is the role of andexanet alfa in the reversal of anticoagulant effects?

Sewell, Jenna Hill; Williams, LaKeisha; McKnight, Ellen; Nguyen, Albert; Sarač, Miroslav S.

doi:10.1097/01.jaa.0000723956.47623.90

Cited by 5 publications

(2 citation statements)

References 6 publications

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“…Multiple professional organizations (American College of Cardiology, American College of Chest Physicians, American College of Emergency Physicians, American College of Gastroenterologists-Canadian College of Gastroenterologists, European Stroke Working Group, Anticoagulation Forum, European Heart Rhythm Association, Swiss Society of Hematology) have recommended Andexxa as a first line agent in the reversal of direct oral factor Xa inhibitors as it relates to major hemorrhage. 12 , 13 , 18 – 23 Despite these recommendations, many levels 1 and 2 trauma centers use PCC for reversal of these drug agents. Our study results supported this; the survey was sent to trauma surgeons associated with levels 1 and 2 trauma centers, with the majority reporting utilization of 4F-PCCs as the personal preference and institutional preference for trauma patients on apixaban and rivaroxaban needing anticoagulation reversal due to life-threatening bleeding.…”

Section: Discussionmentioning

confidence: 99%

Use of Andexanet Alfa for Factor Xa Inhibitor Reversal in US Verified Trauma Centers: A National Survey

Fasanya,

Arrillaga,

Caronia

et al. 2024

Clin Appl Thromb Hemost

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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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Section: Discussionmentioning

confidence: 99%

Use of Andexanet Alfa for Factor Xa Inhibitor Reversal in US Verified Trauma Centers: A National Survey

Fasanya,

Arrillaga,

Caronia

et al. 2024

Clin Appl Thromb Hemost

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“…Andexanet alfa, or "coagulation factor Xa (recombinant) inactivated-zhzo," is a modified recombinant human factor Xa decoy protein that binds and sequesters apixaban and rivaroxaban. It also binds and inhibits tissue factor pathway inhibitor and has an elimination half-life of 5 hours (28). In clinical trials, andexanet alfa decreased apixaban activity by 94% and rivaroxaban activity by 92%.…”

Section: Reversal Of Rivaroxaban or Apixaban With Andexanet Alfamentioning

confidence: 99%

American College of Gastroenterology-Canadian Association of Gastroenterology Clinical Practice Guideline: Management of Anticoagulants and Antiplatelets During Acute Gastrointestinal Bleeding and the Periendoscopic Period

et al. 2022

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We conducted systematic reviews of predefined clinical questions and used the Grading of Recommendations, Assessment, Development and Evaluations approach to develop recommendations for the periendoscopic management of anticoagulant and antiplatelet drugs during acute gastrointestinal (GI) bleeding and the elective endoscopic setting. The following recommendations target patients presenting with acute GI bleeding: For patients on warfarin, we suggest against giving fresh frozen plasma or vitamin K; if needed, we suggest prothrombin complex concentrate (PCC) compared with fresh frozen plasma administration; for patients on direct oral anticoagulants (DOACs), we suggest against PCC administration; if on dabigatran, we suggest against the administration of idarucizumab, and if on rivaroxaban or apixaban, we suggest against andexanet alfa administration; for patients on antiplatelet agents, we suggest against platelet transfusions; and for patients on cardiac acetylsalicylic acid (ASA) for secondary prevention, we suggest against holding it, but if the ASA has been interrupted, we suggest resumption on the day hemostasis is endoscopically confirmed. The following recommendations target patients in the elective (planned) endoscopy setting: For patients on warfarin, we suggest continuation as opposed to temporary interruption (1–7 days), but if it is held for procedures with high risk of GI bleeding, we suggest against bridging anticoagulation unless the patient has a mechanical heart valve; for patients on DOACs, we suggest temporarily interrupting rather than continuing these; for patients on dual antiplatelet therapy for secondary prevention, we suggest temporary interruption of the P2Y12 receptor inhibitor while continuing ASA; and if on cardiac ASA monotherapy for secondary prevention, we suggest against its interruption. Evidence was insufficient in the following settings to permit recommendations. With acute GI bleeding in patients on warfarin, we could not recommend for or against PCC administration when compared with placebo. In the elective periprocedural endoscopy setting, we could not recommend for or against temporary interruption of the P2Y12 receptor inhibitor for patients on a single P2Y12 inhibiting agent. We were also unable to make a recommendation regarding same-day resumption of the drug vs 1–7 days after the procedure among patients prescribed anticoagulants (warfarin or DOACs) or P2Y12 receptor inhibitor drugs because of insufficient evidence.

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Perioperative Stroke

Bard,

McCullough-Hicks

2024

Stroke for the Advanced Practice Clinician

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What is the role of andexanet alfa in the reversal of anticoagulant effects?

Cited by 5 publications

References 6 publications

Use of Andexanet Alfa for Factor Xa Inhibitor Reversal in US Verified Trauma Centers: A National Survey

Use of Andexanet Alfa for Factor Xa Inhibitor Reversal in US Verified Trauma Centers: A National Survey

American College of Gastroenterology-Canadian Association of Gastroenterology Clinical Practice Guideline: Management of Anticoagulants and Antiplatelets During Acute Gastrointestinal Bleeding and the Periendoscopic Period

Perioperative Stroke

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