Emergent Oral Anticoagulant

ReversalFrom (A)ndexanet Alfa to (V)itamin K

Adam Rodos, MD

@ajrodos

University of Illinois Hospital & Health Sciences System

In accordance with the Accreditation Council for Continuing Medical Education (ACCME) Standards and the policy of the ACEP, presenters must disclose the existence of significant financial interests in or relationships with manufacturers or commercial products that may have a direct interest in the subject matter of the presentation, and relationships with the commercial supporter of this CME activity. These presenters do not consider that it will influence their presentation.

Dr. Rodos does not have a significant financial relationship to report.

An evidence informed approach to emergent oral anticoagulant reversal

Option 1

Option 1

Option 1

Option 2

WarfarinDabigatranApixaban

RivaroxabanEdoxaban

Phytonadione (Vitamin K)

10mg IV

Prothrombin Complex Concentrate

50 units/kg* Max Weight 100kg

* http://www.kcentra.com/dosage-calculator for INR based dosing

WarfarinDabigatranApixaban

RivaroxabanEdoxaban

IDARUCIZUMAB2.5g IV x2doses not more than 15 minutes apart

WarfarinDabigatranApixaban

RivaroxabanEdoxaban

Prothrombin Complex Concentrate

50 units/kg Max weight 100kg

Andexanet AlfaCiraparantag

WarfarinDabigatranApixabanRivaroxabanEdoxaban

rodos@uic.edu@ajrodos

• Chai-Adisaksopha, C., Hillis, C., Siegal, D. M., Movilla, R., Heddle, N., Iorio, A., & Crowther, M. (2016). Prothrombin complex concentrates versus fresh frozen plasma for warfarin reversal. Thrombosis and Haemostasis, 116(5), 879–890.

Christos, S., & Naples, R. (2016). Anticoagulation Reversal and Treatment Strategies in Major Bleeding: Update 2016. The Western Journal of Emergency Medicine, 17(3), 264–270.

Connolly, S. J., Milling, T. J., Jr., Eikelboom, J. W., Michael Gibson, C., Curnutte, J. T., … for the ANNEXA-4 Investigators*. (2016). Andexanet Alfa for Acute Major Bleeding Associated with Factor Xa Inhibitors. NEJM, 375, 1131–1141.

Harter, K., Levine, M., & Henderson, S. O. (2015). Anticoagulation Drug Therapy: A Review. The Western Journal of Emergency Medicine, 16(1), 11–17.

Johansen, M., Wikkelsø, A., Lunde, J., Wetterslev, J., & Afshari, A. (2015). Prothrombin complex concentrate for reversal of vitamin K antagonist treatment in bleeding and non-bleeding patients. Cochrane Database of Systematic Reviews , (7). Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/26151108

Kumar, M. A., Frontera, J. A., & Org, F. (2016). Guideline for Reversal of Antithrombotics in Intracranial Hemorrhage. Neurocritical Care, 24, 6–46.

Lip, E. al. (2016). Major Bleeding Risk Among Non-Valvular Atrial Fibrillation Patients Initiated on Apixaban, Dabigatran, Rivaroxaban, or Warfarin: A “Real World” Observational Study in the United States. International Journal of Clinical Practice, 70, 752–763.

Pollack, C. V. (2012). New oral anticoagulants in the ED setting: A review. The American Journal of Emergency Medicine, 30(9), 2046–2054.

Pollack, C. V. (2013). Managing bleeding in anticoagulated patients in the emergency care setting. The Journal of Emergency Medicine, 45(3), 467–477.

Pollack, C. V., Jr., Reilly, P. A., Eikelboom, J., M.B., B.S., … Weitz, A. J. I. (2015). Idarucizumab for Dabigatran Reversal. NEJM, 373, 511–520.

Rodos, M. D. A., & Eilbert, W. (10/2017). Reversing the New Oral Anticoagulants Not as Complicated as You Think. Emergency Medicine News, 39(10), 14–15.

Sartori, M. T., & Prandoni, P. (2016). How to effectively manage the event of bleeding complications when using anticoagulants. Expert Reviews Hematology, 9(1), 37–50.

Siegal, D. M., Curnutte, J. T., Connolly, S. J., Lu, G., Conley, P. B., Wiens, B. L., … Crowther, M. a. (2015a). Andexanet Alfa for the Reversal of Factor Xa Inhibitor Activity. New England Journal of Medicine, 373(25), 2413–2424.

Steiner, T., Poli, S., Griebe, M., Hüsing, J., Hajda, J., Freiberger, A., … Veltkamp, R. (2016). Fresh frozen plasma versus prothrombin complex concentrate in patients with intracranial haemorrhage related to vitamin K antagonists (INCH): a randomised trial. Lancet Neurology, 15(6), 566–573.

Tornkvist, M., Smith, J. G., & Labaf, A. (2017). Current evidence of oral anticoagulant reversal: A systematic review. Thrombosis Research, 162, 22–31.

Writing Committee, Tomaselli, G. F., Mahaffey, K. W., Cuker, A., Dobesh, P. P., Doherty, J. U., … Wiggins, B. S. (2017). 2017 ACC Expert Consensus Decision Pathway on Management of Bleeding in Patients on Oral Anticoagulants: A Report of the American College of Cardiology Task Force on Expert Consensus Decision Pathways. Journal of the American College of Cardiology. https://doi.org/10.1016/j.jacc.2017.09.1085