Template:Factor Xa Inhibitor Reversal: Difference between revisions

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===Factor Xa Inhibitor Reversal===
===[[Anticoagulant reversal for life-threatening bleeds|Factor Xa Inhibitor Reversal]]===
{| {{table}}
{| {{table}}
| align="center" style="background:#f0f0f0;"|'''Anticoagulant'''
| align="center" style="background:#f0f0f0;"|'''Anticoagulant'''
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| align="center" style="background:#f0f0f0;"|'''Strategies to reverse or minimize anticoagulant effects'''
| align="center" style="background:#f0f0f0;"|'''Strategies to reverse or minimize anticoagulant effects'''
|-
|-
| [[Apixaban]] (Eliquis®)||8-15 hrs (longer in renal impairment)||No||
| [[Apixaban]]<ref>Eliquis prescribing information. Princeton, NJ: Bristol Myers Squibb; December 2012.</ref> (Eliquis®)||8-15 hrs (longer in renal impairment)||No||
*If ingested within 2 hours, administer activated charcoal  
*If ingested within 2 hours, administer activated charcoal  
*4-factor PCC (Kcentra™)^  
*4-factor [[PCC]] (Kcentra™)^  
**25units/kg—max 2500 units for treatment of documented intracranial hemorrhage  
**25units/kg—max 2500 units for treatment of documented intracranial hemorrhage  
**50 units/kg—max 5000 units for all other life-threatening bleeds
**50 units/kg—max 5000 units for all other life-threatening bleeds
|-
|-
| [[Edoxaban]] (Savaysa®)||10-14 hrs (longer in renal impairment)||~ 25%||As above
| [[Edoxaban]]<ref>Savaysa prescribing information. Parsippany, NJ: Daiichi Sankyo, Inc.; November 2015.</ref> (Savaysa®)||10-14 hrs (longer in renal impairment)||~ 25%||As above
|-
|-
| [[Rivaroxaban]] (Xarelto®)||9-13 hrs (longer in renal impairment)||No||As above
| [[Rivaroxaban reversal|Rivaroxaban]]<ref>Xarelto prescribing information. Titusville, NJ: Janssen Pharmaceuticals, Inc.; December 2014.</ref> (Xarelto®)||9-13 hrs (longer in renal impairment)||No||As above
|-
|-
| [[Fondaparinux]] (Arixtra®)||17-21 hrs (significantly longer in renal impairment)||No||4-factor [[PCC]] (Kcentra™)^ 50 units/kg—max 5000 units
| [[Fondaparinux]] (Arixtra®)||17-21 hrs (significantly longer in renal impairment)||No||4-factor [[PCC]] (Kcentra™)^ 50 units/kg—max 5000 units
|}
|}
^Off-label
^Off-label
===[[Andexanet alfa]]===
FDA approved in May 2018, limited availability June 2018
*Cost is $20,000 to $55,000 per dose
*Trial that led to FDA approval does not have the most sound evidence behind it <ref>Connolly SJ, Crowther M, Eikelboom JW, et al. Full Study Report of Andexanet Alfa for Bleeding Associated with Factor Xa Inhibitors. N Engl J Med. 2019</ref>:
**Prospective single center single group study of 352 patients receiving a Factor Xa Inhibitor ([[apixaban]], [[rivaroxaban]], [[edoxaban]], [[enoxaparin]]) with life threatening bleed (those with expected survival <1 month were excluded).
**Anti-Factor Xa activity was decreased in all groups. 82% were judged to have excellent hemostatic control. 14% mortality rate at 30 days.
**No comparison group available. It is unlikely that following anti-Factor Xa activity as a lab value is clinically important. High mortality rate even after excluding sick patients.
====Low Dose====
'''400''' mg IV bolus at rate of ~30 mg/minute, followed 2 minutes later by '''4''' mg/minute for up to 120 minutes
====High Dose====
'''800''' mg IV bolus at rate of ~30 mg/minute, followed 2 minutes later by '''8''' mg/minute for up to 120 minutes

Latest revision as of 22:03, 11 February 2020

Factor Xa Inhibitor Reversal

Anticoagulant Half-life Removed by HD Strategies to reverse or minimize anticoagulant effects
Apixaban[1] (Eliquis®) 8-15 hrs (longer in renal impairment) No
  • If ingested within 2 hours, administer activated charcoal
  • 4-factor PCC (Kcentra™)^
    • 25units/kg—max 2500 units for treatment of documented intracranial hemorrhage
    • 50 units/kg—max 5000 units for all other life-threatening bleeds
Edoxaban[2] (Savaysa®) 10-14 hrs (longer in renal impairment) ~ 25% As above
Rivaroxaban[3] (Xarelto®) 9-13 hrs (longer in renal impairment) No As above
Fondaparinux (Arixtra®) 17-21 hrs (significantly longer in renal impairment) No 4-factor PCC (Kcentra™)^ 50 units/kg—max 5000 units

^Off-label

Andexanet alfa

FDA approved in May 2018, limited availability June 2018

  • Cost is $20,000 to $55,000 per dose
  • Trial that led to FDA approval does not have the most sound evidence behind it [4]:
    • Prospective single center single group study of 352 patients receiving a Factor Xa Inhibitor (apixaban, rivaroxaban, edoxaban, enoxaparin) with life threatening bleed (those with expected survival <1 month were excluded).
    • Anti-Factor Xa activity was decreased in all groups. 82% were judged to have excellent hemostatic control. 14% mortality rate at 30 days.
    • No comparison group available. It is unlikely that following anti-Factor Xa activity as a lab value is clinically important. High mortality rate even after excluding sick patients.


Low Dose

400 mg IV bolus at rate of ~30 mg/minute, followed 2 minutes later by 4 mg/minute for up to 120 minutes

High Dose

800 mg IV bolus at rate of ~30 mg/minute, followed 2 minutes later by 8 mg/minute for up to 120 minutes

  1. ↑ Eliquis prescribing information. Princeton, NJ: Bristol Myers Squibb; December 2012.
  2. ↑ Savaysa prescribing information. Parsippany, NJ: Daiichi Sankyo, Inc.; November 2015.
  3. ↑ Xarelto prescribing information. Titusville, NJ: Janssen Pharmaceuticals, Inc.; December 2014.
  4. ↑ Connolly SJ, Crowther M, Eikelboom JW, et al. Full Study Report of Andexanet Alfa for Bleeding Associated with Factor Xa Inhibitors. N Engl J Med. 2019
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