Management of Life-Threatening Bleeding In The Anticoagulated Patient In The Emergency Setting And The Impact of ANNEXA-4 On The Treatment of Patients Taking Factor Xa Inhibitors

Management of severe bleeding in patients taking oral anticoagulants is complicated. Acute care physicians must be knowledgeable about the individual oral anticoagulant agents, the general management of anticoagulant-associated bleeding, and the strategies for effective use of factor repletion and specific reversal agents. With any oral anticoagulant, minor or “nuisance” bleeding is most common and can be managed without repletion or reversal. For major oral anticoagulant-associated bleeding, class-specific approaches should be used and the necessary treatment agents made readily available in the Emergency Department (ED), the Intensive Care Unit (ICU), and the surgical suite. Because the reversal agents for warfarin, the thrombin inhibitor dabigatran and the Factor Xa inhibitors apixaban and rivaroxaban are expensive and, like all therapies, have the potential for causing their own adverse events, acute care physicians must be sufficiently informed as to the risks and benefits before using these important new therapies.

In this newsletter, approved anticoagulant therapies, including warfarin, Factor IIa inhibitors, and Factor Xa inhibitors, will be reviewed. Second, the disease indications for anticoagulation, particularly VTE and AF, will be discussed. Third, the available repletion and reversal agents, including fresh frozen plasma (FFP), prothrombin complex concentrates (PCCs), andexanet alfa for the Factor Xa inhibitors rivaroxaban and apixaban, and idarucizumab for the Factor IIa inhibitor dabigatran, will be described. And finally, the ANNEXA-4 Final Study results, published in February 2019 in the New England Journal of Medicine, will be reviewed.