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A review of oral anticoagulants, old and new, in major bleeding and the need for urgent surgery.

Authors
  • Milling, Truman J Jr1
  • Ziebell, Christopher M2
  • 1 Department of Surgery and Perioperative Care, Dell Medical School, Austin, TX, USA; Department of Neurology, Seton Dell Medical School Stroke Institute, 1400 N IH 35 Suite C3.400, Austin, Texas 78701. Electronic address: [email protected]
  • 2 Department of Surgery and Perioperative Care, Dell Medical School, Austin, TX, USA.
Type
Published Article
Journal
Trends in cardiovascular medicine
Publication Date
Feb 01, 2020
Volume
30
Issue
2
Pages
86–90
Identifiers
DOI: 10.1016/j.tcm.2019.03.004
PMID: 30952383
Source
Medline
Keywords
Language
English
License
Unknown

Abstract

Oral anticoagulants, old and new, are effective therapies for prevention and treatment of venous thromboembolism and reduction of stroke risk in patients with atrial fibrillation. However, blocking elements of the clotting cascade carries an inherent risk of bleeding. Also, anticoagulated patients sometimes require urgent surgery or invasive procedures. This has led to the emergence of a body of scientific literature on the reversal of anticoagulation in these two settings. Traditionally, vitamin K antagonists (VKAs), which indirectly inactivate clotting factors II, VII, IX and X (and natural anticoagulant proteins C and S), had been the mainstay of oral anticoagulation for half a century. Only a few years ago, the US Food and Drug Administration (FDA) approved a specific VKA reversal agent, 4-Factor Prothrombin Complex Concentrate (4F-PCC). The last decade has seen the rise of non-Vitamin K oral anticoagulants (NOACs), which target specific factors, i.e. Factors IIa and Xa. Investigators have rapidly developed reversal agents for these agents as well, idarucizumab for the Factor IIa inhibitor dabigatran (Pradaxa) and andexanet alfa for the entire class of Factor Xa inhibitors (FXaIs), currently four drugs: rivaroxaban (Xarelto), apixaban (Eliquis), edoxaban (Savaysa) and betrixaban (Bevyxxa). Clinicians still use off-label PCC for reversing FXaIs in some settings, and a universal reversal agent, ciraparantag, remains in development. This review summarizes the safety and efficacy of these reversal agents in the setting of anticoagulant-associated major bleeding and the need for urgent surgery. Copyright © 2019 Elsevier Inc. All rights reserved.

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