From the Guidelines
Antidotes for Novel Oral Anticoagulants (NOACs)
For patients experiencing bleeding complications while on novel oral anticoagulants (NOACs), specific antidotes are available. Idarucizumab is the antidote for dabigatran, administered as a 5g intravenous dose 1. Andexanet alfa is the antidote for rivaroxaban and apixaban, administered as an initial intravenous bolus of 400-800mg, followed by a continuous infusion of 4-8mg/min for up to 2 hours 1.
- Key points to consider:
- Idarucizumab is specifically used for dabigatran reversal 1.
- Andexanet alfa is used for the reversal of oral factor Xa inhibitors, such as rivaroxaban and apixaban 1.
- Prothrombin complex concentrate (PCC) may be considered as an adjunctive treatment for NOAC-associated bleeding, although its effectiveness varies among different NOACs 1.
- Important Considerations:
- The decision to use an antidote should be based on the severity of the bleeding and the clinical context 1.
- For life-threatening hemorrhage, idarucizumab or andexanet alfa may be considered 1.
- The timing of restarting anticoagulant therapy after a bleeding event should be carefully considered, balancing the risk of thrombosis against the risk of rebleeding 1.
From the Research
Antidotes for Novel Oral Anticoagulants (NOACs)
- There are no specific antidotes available for all NOACs, but some target-specific antidotes are in development and have shown promise for NOAC reversal 2.
- Idarucizumab is a specific antidote for dabigatran, a factor IIa inhibitor, and andexanet alfa is a specific antidote for factor Xa inhibitors (rivaroxaban, apixaban, edoxaban) 3, 4.
- Non-specific prohemostatic therapies such as prothrombin complex concentrate (PCC) or activated prothrombin complex concentrate (aPCC) may be considered in addition to supportive measures for patients with severe or life-threatening bleeding 2, 5, 6.
- The use of 4-factor PCC or 3-factor PCC at a dose of about 50 U/kg may be given in an emergency setting to manage bleeding related to factor Xa inhibitors such as rivaroxaban or apixaban 6.
- Activated charcoal may be given in the setting of early overdose of dabigatran (within 3-4 hours), and hemodialysis may be used if there is evidence of critical organ bleeding 6.
Management of Bleeding Complications
- The management of bleeding complications in patients on NOAC therapy can be challenging due to the limited availability of antidotes and the lack of routine laboratory test monitoring the NOAC anticoagulant effect 4.
- In case of life-threatening or critical site bleeding, reversal of NOAC anticoagulant activity is essential together with immediate implementation of causative treatment 4.
- The decision to resume anticoagulation after a bleeding event should be made on a case-by-case basis, taking into account the risk of thromboembolic complications and the risk of recurrent bleeding 3.