This stuff is not flashy and frankly, it hurts my head. That is all the more reason to do a show on the new landscape of NOAC reversal. We must pursue rather than avoid the subjects we are weak on. But I needed someone far smarter than myself–I needed a EM PharmD. Nobody better to speak about this topic than Nadia Awad. Nadia is associate editor of the Emergency Medicine PharmD Blog. She is an Emergency Medicine Pharmacist at the Robert Wood Johnson University Hospital in New Jersey.

Laboratory Parameters for Monitoring Target-Specific Oral Anticoagulants

• Hawes EM et al. J Thromb Haemost 2013; 11:1493-1502.
• Cuker A et al. J Am Coll Cardiol 2014; 64:1128-1139.
• Favaloro EJ et al. Semin Thromb Hemost 2015; 41:208-227.
• Samuelson BT et al. Blood Reviews 2017; 31:77-84.

Interim Analysis of Idarucizumab: REVERSE-AD

• Pollack CV et al. N Engl J Med 2015; 373:511-20.

Clinical Experiences Reported in Literature with Idarucizumab Following Approval by FDA

• Reviewed on Emergency Medicine PharmD

Fantastic Review on Idarucizumab

• Miller et al.

Use of Extracorporeal Measures to Expedite Elimination of Dabigatran in the Setting of Life-Threatening Bleeding

• Awad NI et al. J Med Toxicol 2015; 11:85-95.

Andexanet Alfa

• Siegal DM et al. N Engl J Med 2015; 373:2413-2424.
• Connolly SJ et al. N Engl J Med 2016; 375:1131-1141.

Low-Dose FEIBA for ICH Induced by Factor Xa Inhibitors

Mao G et al. JEM 2016 [Epub ahead of print].

Aripazine (PER977) AKA Ciraparantag

• Ansell JE et al. N Engl J Med 2014; 22:2141-2142.
• Ansell JE et al. Thromb Haemost 2017; 117:238-245.

Recommendations for Reversal of ICH Induced by Antithrombotics from Neurocritical Care Society

• Frontera JA et al. Neurocrit Care 2016; 24:6-46.

Excellent reviews on Idarucizumab

• Ann Emerg Med 2017;69(5):554
• EM Lit of Note

Dosing

Monoclonal antibody
works within minutes
Thrombin time and ECT are best monitoring, aPTT if stone-cold normal prob. rules out Dabi
Package comes with 2 vials
2.5 gm each
5 gms is the initial dose
Give each over 5 minutes
Spike and hang vial
give 2nd vial with 15 minutes of first (no reason not to give immediately)
$4200 for both vials at Janus General
Dabi lasts 12 hours in normal patients, and antidote lasts same ostensibly

Kcentra Studies

• RCT of Kcentra (Circulation 2013;128:1234)

Dosing

INR

• 2-3.9: 25 units/kg (2500 max)
• 4-5.9: 35 units/kg (3500 max)
• >6:     50 units/kg (5000 max)

• Repeat dosing is not recommended, but that doesn't apply to giving fixed dose and then adding on, IMO
• Package insert discusses 8.4 ml/minute (210 units/minute) as max rate, but literature supports more rapid administration [cite]19787352[/cite]
• Here is a study on the fixed dose use of Kcentra (American Journal of Emergency Medicine 33 (2015) 1213–1218)

More

• I'll be doing an upcoming show on reversal-when is it safe, when is it smart
• Previous Page on Dabi Reversal

• FEIBA is probably safe when given as fixed dose (500 IU for INR < 5 and 1000 IU for >= 5) [Crit Care Med. 2018;46(6):943-948. [PubMed]
• SR shows no benefit of Andexanet but increased complications. Orso et al. Critical Care (2024) 28:221 https://doi.org/10.1186/s13054-024-05014-x

Additional New Information

ANNEXA-I showed increased complications compared to standard care (a large portion of which got 4-factor PCC) [10.1056/NEJMoa2313040]

More on EMCrit

• EMCrit CQIR – The Conundrum of Reversing Anticoagulants for Mechanical Heart Valves in Intracranial Hemorrhage(Opens in a new browser tab)
• EMCrit 319 – Safe and Smart Reversal of Anticoagulation / Anti-platelet Agents in 2022(Opens in a new browser tab)
• Anticoagulant reversal(Opens in a new browser tab)

Additional Resources

• Author
• Recent Posts

Scott Weingart, MD FCCM

Editor-in-Chief, at EMCrit.org

An ED Intensivist from NY.
Professor
Nassau University Medical Center
No conflicts of interest (coi).

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