Lynchburg Journal of Medical Science

Lynchburg Journal of Medical Science


Critical Care


Beth Hart, hart_ea@lynchburg.edu


Anticoagulation is a necessary component of modern healthcare and is used to treat thromboembolic conditions such as venous thromboembolism (VTE) and pulmonary embolism (PE), prevent stroke in patients with atrial fibrillation (AF), and more. Introduced over half a century ago, warfarin, a vitamin K antagonist, has been the preferred anticoagulant.2 However, in 2009 direct oral anticoagulants were introduced and since then, the landscape of anticoagulation has been rapidly evolving. Recent trends in anticoagulation utilization reveal that the use of warfarin is steadily declining while the use of direct oral anticoagulants (DOACs) is rapidly increasing.2

The DOACs include four factor Xa inhibitors (FXaI) and one direct thrombin inhibitor (DTI): apixaban, edoxaban, betrixaban, rivaroxaban, and dabigatran, respectively.2 Compared to warfarin, DOACs have been shown to be safer, more efficacious, require less monitoring, and have fewer drug interactions.2

As expected, bleeding is the most common adverse effect when using anticoagulants. Reversal of anticoagulants is integral to preventing adverse outcomes from unexpected hemorrhage, including paralysis or even death. It is also sometimes necessary for patients who need emergent surgical procedures. Currently, the only approved agent for the reversal of dabigatran (DTI) is idarucizumab.2 In recent years, the use of prothrombin complex concentrates (PCCs) were recommended for the reversal of FXaIs.2 As of 2019, andexanet alfa has also been approved for reversal of FXaIs.3 In summary, the current recommendations of reversal are 4 factor PCCs and andexanet alfa for FXaIs, and idarucizumab for the DTI.4


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