Key result
US trauma surgeons prefer 4F-PCC over andexanet alfa ~67% vs. ~26%, primarily driven by cost.
Why the study?
Barriers such as cost and a lack of grade 1A evidence comparing PCC to andexanet alfa may limit utilization of andexanet alfa for factor Xa inhibitor reversal in trauma centers.
What are the practice preferences and perceived barriers among US trauma surgeons regarding the use of andexanet alfa versus 4-factor prothrombin complex concentrate for factor Xa inhibitor reversal in trauma patients?
Cross-Sectional (n=89)
Yes
What are the practice preferences and perceived barriers among US trauma surgeons regarding the use of andexanet alfa versus 4-factor prothrombin complex concentrate for factor Xa inhibitor reversal in trauma patients?
Answers are grounded in this paper and cite their sources.
Despite professional society guidelines recommending andexanet alfa, most surveyed US trauma surgeons and trauma centers preferentially use 4F-PCC for factor Xa inhibitor reversal due to prohibitive cost and perceived lack of high-level comparative efficacy data in trauma.
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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Fasanya et al. (2024) conducted a cross-sectional in Factor Xa inhibitor reversal in life-threatening trauma bleeding (n=89). Andexanet alfa vs. 4-factor prothrombin complex concentrate (4F-PCC) was evaluated on Surgeon-preferred first-line reversal agent for life-threatening bleeding in adult trauma patients on apixaban or rivaroxaban (p=<0.01). Andexanet alfa was preferred by only 25.8% of US trauma surgeons as first-line reversal for adults vs 67.4% for 4F-PCC (p<0.01), primarily due to cost (76.3%).
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