Title:A Review on the Use of Reversal Agents of Direct Oral Anticogulant Drugs in Case of Gastrointestinal Bleeding
VOLUME: 15 ISSUE: 4
Author(s):Veronica Ojetti*, Angela Saviano, Mattia Brigida, Luisa Saviano, Alessio Migneco and Francesco Franceschi
Affiliation:Department of Emergency Medicine Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Universita Cattolica del Sacro Cuore, Rome, Universita Cattolica del Sacro Cuore, Rome, Department of Emergency Medicine Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Department of Emergency Medicine Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Department of Emergency Medicine Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome
Keywords:bleeding, reversal agents, DOACs, idarucizumab, andexanet alfa, ciraparantag
Abstract:
Background: Major bleeding is a life-threatening condition and a medical emergency
with high mortality risk. It is often the complication of anticoagulant’s intake. Anticoagulants are
commonly used for the prevention and treatment of thrombotic events. The standard therapy with
vitamin K antagonist (warfarin) has been frequently replaced by direct oral anticoagulants (DOACs).
The latter agents (rivaroxaban, apixaban, edoxaban, dabigatran, and betrixaban) showed better
efficacy and safety compared to standard warfarin treatment and they are recommended for the reduction
of ischemic stroke. Literature data reported a high risk of gastrointestinal bleeding with
DOACs, in particular with dabigatran and rivaroxaban. In case of life-threatening gastrointestinal
bleeding, these patients could benefit from the use of reversal agents.
Methods: We performed an electronic search on PUBMED of the literature concerning reversal
agents for DOACs and gastrointestinal bleeding in the Emergency Department from 2004 to 2020.
Aim: This review summarizes the current evidence about three reversal agents idarucizumab, andexanet
alfa and ciraparantag, and the use of the first two in the emergency setting in patients with
active major bleeding or who need urgent surgery which physicians indicate for a better management
approach in order to increase patient’s safety.
Conclusion: Although these agents have been marketed for five years (idarucizumab) and two
years (andexanet alfa) respectively, and despite guidelines considering antidotes as first-line agents
in treating life-threatening hemorrhage when available, these antidotes seem to gain access very
slowly in the clinical practice. Cost, logistical aspects and need for plasma level determination of
DOAC for an accurate therapeutic use probably have an impact on this phenomenon.. An expert
multidisciplinary bleeding team should be established so as to implement international guidelines
based on local resources and organization.
