Key result
Standard in-house coagulation assays (PT, aPTT, LMWH anti-factor Xa) failed to rapidly and accurately detect clinically relevant apixaban levels prior to andexanet alfa reversal in three patients with intracranial hemorrhage.
Why the study?
Clinicians face challenges initiating emergent andexanet alfa reversal when the timing of last factor Xa inhibitor dose is unknown, turnaround times for anti-factor Xa levels are prolonged, or patients fall outside recommended timeframes.
Case Report (n=3)
No
Institutions need rapid and accurate methods to detect clinically relevant factor Xa inhibitor levels to guide appropriate use of andexanet alfa in emergent bleeding.
May complicate andexanet alfa decisions in ICH without known dosing history; leaves open need for faster anti-Xa testing or protocols.
Coagulation factor Xa (recombinant), inactivated-zhzo (andexanet alfa) is approved for reversal of life-threatening bleeding with rivaroxaban and apixaban use. Clinical decision-making to initiate reversal is reliant on dose taken and timing of last dose. In practice, timing of last dose may be unknown, and the turnaround time for drug-specific anti-factor Xa levels at some institutions may be prolonged, leaving clinicians balancing a difficult decision with limited tools. This report includes a series of 3 patients who presented to our institution with an intracranial hemorrhage and received andexanet alfa for apixaban reversal. These cases highlight the challenges clinicians are facing when using andexanet alfa for emergent rivaroxaban or apixaban reversal when the timing of last dose is unknown, or patients fall outside of the recommended timeframe for use and clinically relevant drug levels are still suspected. Based on our experiences, we encourage other institutions to evaluate their abilities to rapidly and accurately detect the presence of clinically relevant rivaroxaban and apixaban levels when utilizing andexanet alfa.
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Davis et al. (2021) conducted a case report in Intracranial hemorrhage on apixaban (n=3). Andexanet alfa was evaluated on Detection of clinically relevant factor Xa inhibitor levels using standard in-house coagulation assays. Standard in-house coagulation assays (PT, aPTT, LMWH anti-factor Xa) failed to rapidly and accurately detect clinically relevant apixaban levels prior to andexanet alfa reversal in three patients with intracranial hemorrhage.
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