Rivaroxaban-Associated Intraparenchymal Hemorrhage Managed with 4-Factor Prothrombin Complex Concentrate
Purpose of Review Background: Rivaroxaban is a Xa inhibitor and one of the direct acting oral anticoagulants (DOAC) that currently does not have evidence-based guidelines for its reversal. Prothrombin complex concentrate (PCC) has been recommended as a potential reversal agent for life-threatening b...
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| Published in: | Current emergency and hospital medicine reports Vol. 6; no. 2; pp. 62 - 68 |
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01.06.2018
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| ISSN: | 2167-4884, 2167-4884 |
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| Abstract | Purpose of Review
Background: Rivaroxaban is a Xa inhibitor and one of the direct acting oral anticoagulants (DOAC) that currently does not have evidence-based guidelines for its reversal. Prothrombin complex concentrate (PCC) has been recommended as a potential reversal agent for life-threatening bleeds. With no direct antidote and its widespread usage, the attempt to manage life-threatening hemorrhages with procoagulant drugs will continue to rise.
Recent Findings
Case report :A 55-year-old male on rivaroxaban and clopidogrel presented to another facility with ataxia, confusion, and lateralizing weakness. Computed tomography (CT) scan of the brain showed a large intraparenchymal hemorrhage. He was intubated, given mannitol and nicardipine, and transferred to our tertiary care facility. His coagulation studies upon arrival were normal. He was given 50 units/kg of PCC in an attempt to reverse rivaroxaban and one unit of platelets for clopidogrel reversal. A repeat CT 18 h later showed extension of the bleed. Neurosurgical intervention was not done, and 4 days into his stay, a right cephalic vein thrombosis was found. During his hospital stay, the patient developed encephalopathy and required a tracheostomy tube and gastrostomy tube. A CT on day 36 showed stabilization of the bleeds, and on day 42, he was transferred to a skilled nursing facility.
Summary
Why should an emergency physician be aware of this? Novel oral anticoagulants are becoming ever popular due to their ease in management and lack of required monitoring when compared to conventional therapy. But, they are still associated with hemorrhages, which is their most common complication. Due to the lack of antidotes and reversal agents for DOACs, prothrombotic agents are being frequently utilized in the setting of life-threatening hemorrhages. While various case reports have been published on the usage of varying dosages of PCC to treat rivaroxaban-associated bleeds, no strong evidence exists to its clinical efficacy. Our case adds to the growing body of evidence showing a lack of clinical efficacy in the reversal of the anticoagulation effects of oral factor Xa inhibitors in addition to a complication in utilizing this potential reversal agent (J Crit Care 33:252–6, 2016; J Thromb Heamost 12:1428–1436, 2014; World Neurosurg 84(6)1956–1961, 2015) |
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| AbstractList | Purpose of ReviewBackground: Rivaroxaban is a Xa inhibitor and one of the direct acting oral anticoagulants (DOAC) that currently does not have evidence-based guidelines for its reversal. Prothrombin complex concentrate (PCC) has been recommended as a potential reversal agent for life-threatening bleeds. With no direct antidote and its widespread usage, the attempt to manage life-threatening hemorrhages with procoagulant drugs will continue to rise.Recent FindingsCase report :A 55-year-old male on rivaroxaban and clopidogrel presented to another facility with ataxia, confusion, and lateralizing weakness. Computed tomography (CT) scan of the brain showed a large intraparenchymal hemorrhage. He was intubated, given mannitol and nicardipine, and transferred to our tertiary care facility. His coagulation studies upon arrival were normal. He was given 50 units/kg of PCC in an attempt to reverse rivaroxaban and one unit of platelets for clopidogrel reversal. A repeat CT 18 h later showed extension of the bleed. Neurosurgical intervention was not done, and 4 days into his stay, a right cephalic vein thrombosis was found. During his hospital stay, the patient developed encephalopathy and required a tracheostomy tube and gastrostomy tube. A CT on day 36 showed stabilization of the bleeds, and on day 42, he was transferred to a skilled nursing facility.SummaryWhy should an emergency physician be aware of this? Novel oral anticoagulants are becoming ever popular due to their ease in management and lack of required monitoring when compared to conventional therapy. But, they are still associated with hemorrhages, which is their most common complication. Due to the lack of antidotes and reversal agents for DOACs, prothrombotic agents are being frequently utilized in the setting of life-threatening hemorrhages. While various case reports have been published on the usage of varying dosages of PCC to treat rivaroxaban-associated bleeds, no strong evidence exists to its clinical efficacy. Our case adds to the growing body of evidence showing a lack of clinical efficacy in the reversal of the anticoagulation effects of oral factor Xa inhibitors in addition to a complication in utilizing this potential reversal agent (J Crit Care 33:252–6, 2016; J Thromb Heamost 12:1428–1436, 2014; World Neurosurg 84(6)1956–1961, 2015) Purpose of Review Background: Rivaroxaban is a Xa inhibitor and one of the direct acting oral anticoagulants (DOAC) that currently does not have evidence-based guidelines for its reversal. Prothrombin complex concentrate (PCC) has been recommended as a potential reversal agent for life-threatening bleeds. With no direct antidote and its widespread usage, the attempt to manage life-threatening hemorrhages with procoagulant drugs will continue to rise. Recent Findings Case report :A 55-year-old male on rivaroxaban and clopidogrel presented to another facility with ataxia, confusion, and lateralizing weakness. Computed tomography (CT) scan of the brain showed a large intraparenchymal hemorrhage. He was intubated, given mannitol and nicardipine, and transferred to our tertiary care facility. His coagulation studies upon arrival were normal. He was given 50 units/kg of PCC in an attempt to reverse rivaroxaban and one unit of platelets for clopidogrel reversal. A repeat CT 18 h later showed extension of the bleed. Neurosurgical intervention was not done, and 4 days into his stay, a right cephalic vein thrombosis was found. During his hospital stay, the patient developed encephalopathy and required a tracheostomy tube and gastrostomy tube. A CT on day 36 showed stabilization of the bleeds, and on day 42, he was transferred to a skilled nursing facility. Summary Why should an emergency physician be aware of this? Novel oral anticoagulants are becoming ever popular due to their ease in management and lack of required monitoring when compared to conventional therapy. But, they are still associated with hemorrhages, which is their most common complication. Due to the lack of antidotes and reversal agents for DOACs, prothrombotic agents are being frequently utilized in the setting of life-threatening hemorrhages. While various case reports have been published on the usage of varying dosages of PCC to treat rivaroxaban-associated bleeds, no strong evidence exists to its clinical efficacy. Our case adds to the growing body of evidence showing a lack of clinical efficacy in the reversal of the anticoagulation effects of oral factor Xa inhibitors in addition to a complication in utilizing this potential reversal agent (J Crit Care 33:252–6, 2016; J Thromb Heamost 12:1428–1436, 2014; World Neurosurg 84(6)1956–1961, 2015) |
| Author | Patel, Jayme S. K. Rahbar, Aryan J. Patel, Ketan Sigal, Tiffany W. |
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| Cites_doi | 10.1007/s00392-013-0560-7 10.1160/TH12-03-0179 10.1111/jth.12599 10.1016/j.jemermed.2013.03.016 10.1160/TH12-12-0907 10.1016/j.ajem.2014.01.042 10.1093/eurheartj/ehs408 10.1056/NEJMoa0905561 10.1097/ALN.0b013e318238c036 10.1056/NEJMoa1007903 10.1016/j.ajem.2013.11.044 10.1016/j.jemermed.2016.11.011 10.1056/NEJMoa0800374 10.1056/NEJMoa1302507 10.1111/jth.12236 10.1016/j.thromres.2014.01.017 10.1056/NEJMoa1607887 10.1016/S0140-6736(08)60880-6 10.1177/1076029613494468 10.1002/phar.1270 10.1136/postgradmedj-2016-134486 10.1007/s11936-013-0238-5 10.2146/ajhp150810 10.3949/ccjm.80a.13025 10.1056/NEJMc1411800 10.1016/j.jcrc.2016.02.018 10.1016/j.jacc.2014.05.065 10.1056/NEJMoa1107039 10.1056/NEJMoa1306638 10.1016/j.wneu.2015.08.042 10.1056/NEJMoa1510991 10.1016/j.acvd.2013.04.009 10.1007/s40262-013-0100-7 10.1056/NEJMoa1009638 10.1586/erc.11.62 10.1056/NEJMoa1113572 10.1161/CIRCULATIONAHA.113.004450 10.1161/CIRCULATIONAHA.111.029017 10.2146/ajhp130041 10.1016/j.ajem.2014.01.049 10.1056/NEJMoa076016 10.1161/STROKEAHA.112.675231 10.1016/j.cjca.2014.01.015 |
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| Keywords | Rivaroxaban PCC Kcentra Intraparenchymal hemorrhage Prothrombin complex concentrate Intracerebral hemorrhage ICH Anticoagulant reversal |
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| References | PerzbornEHeitmeierSLauxVBuchmüllerAReversal of rivaroxaban-induced anticoagulation with prothrombin complex concentrate, activated prothrombin complex concentrate and recombinant activated factor VII in vitroThromb Res201413367168110.1016/j.thromres.2014.01.017 SiegalDCurnutteJConnollySAndexanet alfa for the reversal of factor Xa inhibitor activityN Engl J Med2015373241324241:CAS:528:DC%2BC28XitFc%3D10.1056/NEJMoa151099126559317 GonzvaJPatricelliRLignacDSpontaneous splenic rupture in a patient treated with rivaroxabanAm J Emerg Med201432950.e310.1016/j.ajem.2014.01.04924612597 AgnelliGBullerHRCohenACurtoMGallusASJohnsonMMasiukiewiczUPakRThompsonJRaskobGEWeitzJIAMPLIFY InvestigatorsOral apixaban for the treatment of acute venous thromboembolismN Engl J Med20133697998081:CAS:528:DC%2BC3sXhtlyis7fN10.1056/NEJMoa130250723808982 Hokusai-VTE InvestigatorsEdoxaban versus warfarin for the treatment of symptomatic venous thromboembolismN Engl J Med20133691406141510.1056/NEJMoa1306638 SchulmanSKakkarAKGoldhaberSZSchellongSErikssonHMismettiPChristiansenAVFriedmanJle MaulfFPeterNKearonCfor the RE-COVER II Trial Investigators*Treatment of acute venous thromboembolism with dabigatranCirculation20141297647721:CAS:528:DC%2BC2cXjtlSnsr0%3D10.1161/CIRCULATIONAHA.113.00445024344086 MueckWStampfussJKubitzaDBeckaMClinical pharmacokinetic and pharmacodynamic profile of rivaroxabanClin Pharmacokinet20145311161:CAS:528:DC%2BC2cXksVaktw%3D%3D10.1007/s40262-013-0100-723999929 KaatzSKouidesPAGarciaDAGuidance on the emergent reversal of oral thrombin and factor 317 Xa inhibitorsAm J Hematol201289S414S145 PernodGAlbaladejoPGodierASamamaCMSusenSGruelYBlaisNFontanaPCohenALlauJVRosencherNSchvedJFde MaistreESamamaMMMismettiPSiéPWorking Group on Perioperative HaemostasisManagement of major bleeding complications and emergency surgery in patients on long-term treatment with direct oral anticoagulants, thrombin or factor Xa 320 inhibitors: proposals of the Working Group on Perioperative Haemostasis (GIHP) – March 2013Arch Cardiovasc Dis201310638239310.1016/j.acvd.2013.04.00923810130 SteinerTBohmMDichgansMRecommendations for the emergency management of complications associated with the new direct oral anticoagulants (DOACs), apixaban, dabigatran, and rivaroxabanClin Res Cardiol20131023994121:CAS:528:DC%2BC3sXnvFSqt7s%3D10.1007/s00392-013-0560-723669868 CukerASiegalDCrowtherMLaboratory measurement of the anticoagulant activity of the non-vitamin K oral anticoagulantsJ Am Coll Cardiol201464112811391:CAS:528:DC%2BC2cXhsFerurjL10.1016/j.jacc.2014.05.065252126484167772 MaoGKingLYoungSKaplanRFactor eight inhibitor bypassing agent (FIEBA) for reversal of target specific oral anticoagulants in life-threatening intracranial bleedingJ EmergMed201752573173710.1016/j.jemermed.2016.11.011 GrangerCBAlexanderJHMcMurrayJLopesRDHylekEMHannaMal-KhalidiHRAnsellJAtarDAvezumABahitMCDiazREastonJDEzekowitzJAFlakerGGarciaDGeraldesMGershBJGolitsynSGotoSHermosilloAGHohnloserSHHorowitzJMohanPJanskyPLewisBSLopez-SendonJLPaisPParkhomenkoAVerheugtFWZhuJWallentinLARISTOTLE Committees and InvestigatorsApixaban versus warfarin in patients with atrial fibrillationN Engl J Med20113659819921:CAS:528:DC%2BC3MXhtF2ms7rN10.1056/NEJMoa110703921870978 AgenoWGallusASWittkowskyAOral anticoagulant therapy: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice GuidelinesChest20122Supple445e885 ErikssonBIBorrisLCFriedmanRJHaasSHuismanMVKakkarAKBandelTJBeckmannHMuehlhoferEMisselwitzFGeertsWRECORD1 Study GroupRivaroxaban versus enoxaparin for thromboprophylaxis after hip arthroplastyN Engl J Med2008358276527751:CAS:528:DC%2BD1cXnvFahtbo%3D10.1056/NEJMoa080037418579811 EerenbergESKamphuisenPWSijpkensMKReversal of rivaroxaban and dabigatran by 337 prothrombin complex concentrate. A randomized, placebo-controlled, crossover study in healthy 338 subjectsCirculation2011124157315791:CAS:528:DC%2BC3MXht1GjsLfO10.1161/CIRCULATIONAHA.111.02901721900088This study reports a complete reversal of elevated prothrombin time (PT) and normalization of endogenous thrombin potential (ETP) following administration of 4-factor PCC in humans given rivaroxaban. In summary, this study provides evidence for successful reversal of rivaroxaban with 4-factor PCC via markers of PT and ETP. GrandhiRNewmanCZhangXAdministration of 4-factor prothrombin complex concentrate as in antidote for intracranial bleeding in patients taking direct factor Xa inhibitorsWorld Neurosurg20158461956196110.1016/j.wneu.2015.08.04226341438 PerzbornEGruberATinelHMarzecUMBuetehornUBuchmuellerAHeitmeierSLauxVReversal of rivaroxaban anticoagulation by haemostatic agents in rats and primatesThromb Haemost20131101621721:CAS:528:DC%2BC3sXhtFKls7jL10.1160/TH12-12-090723636219 AnsellJBakhruSLaulichtBUse of PER977 to reverse the anticoagulant effect of edoxabanN Engl J Med20143712141214210.1056/NEJMc141180025371966 SiegalDMCrowtherMAAcute management of bleeding in patients on novel oral anticoagulantsEur 313 Heart J2013344895001:CAS:528:DC%2BC3sXivFaqtLk%3D10.1093/eurheartj/ehs408 PatelMRMahaffeyKWGargJRivaroxaban versus warfarin in nonvalvular atrial fibrillationN 302 Engl J Med20113658838911:CAS:528:DC%2BC3MXhtFKhsLnI10.1056/NEJMoa1009638 KakkarAKBrennerBDahlOEErikssonBIMouretPMuntzJSoglianAGPapÁFMisselwitzFHaasSExtended duration rivaroxaban versus short-term enoxaparin for the prevention of venous thromboembolism after total hip arthroplasty: a double-blind, randomized controlled trialLancet200837231391:CAS:528:DC%2BD1cXotlWqsrg%3D10.1016/S0140-6736(08)60880-618582928 RileyTGauthier-LewisMSanchezCRole of agents for reversing the effects of target-specific oral anticoagulantsAm J Health-Syst Pharm2017742546110.2146/ajhp15081027895055This article looked at the various different mechanisms for reversing oral anticoagulants. It also reviewed the latest information on the new reversal agents that are still currently in early trials, but may show some promising effects for reversing oral anticoagulants, especially factor Xa inhibitors. FawoleADawHACrowtherMAPractical management of bleeding due to the anticoagulants dabigatran, rivaroxaban, and apixabanCleve Clin J Med21038044345110.3949/ccjm.80a.13025 PollackCVManaging bleeding in anticoagulated patients in the emergency care settingJ Emerg Med20134546747710.1016/j.jemermed.2013.03.01623786779 KalusJSPharmacologic interventions for reversing the effects of oral anticoagulantsAm J Health-Syst Pharm201370S12S211:CAS:528:DC%2BC3sXptVWqtrY%3D10.2146/ajhp13004123640528 AkwaaFSpyropoulosACTreatment of bleeding complications when using oral anticoagulants for 332 prevention of strokesCurr Treat Options Cardiovasc Med20131528829810.1007/s11936-013-0238-523494907 LassenMRAgenoWBorrisLCLiebermanJRRosencherNBandelTJMisselwitzFTurpieAGRECORD3 InvestigatorsRivaroxaban versus enoxaparin for thromboprophylaxis after total knee arthroplastyN Engl J Med2008358277627861:CAS:528:DC%2BD1cXnvFagt70%3D10.1056/NEJMoa07601618579812 LeviMMooreKCastillejosCComparison of three-factor and four-factor prothrombin complex concentrates regarding reversal of the anticoagulant effects of rivaroxaban in healthy volunteersJ Thromb Heamost201412142814361:CAS:528:DC%2BC2cXhsFCjurzP10.1111/jth.12599This study was unable to completely reverse the PT as described in the Eerenberg study. In addition, 4-factor PCC did not produce as robust of a reversal of ETP that 3-factor PCC did. Both 3-factor and 4-factor PCC did not have an effect on activated partial thromboplastin time (APTT). In summary, this study presents evidence for a more muted response to PCC as compared to the Eerenberg study. ZhouWZornMNawrothPButehornUPerzbornEHeitmeierSVeltkampRHemostatic therapy in experimental intracerebral hemorrhage associated with rivaroxabanStroke2013447717781:CAS:528:DC%2BC3sXms1ylt70%3D10.1161/STROKEAHA.112.67523123339956 The EINSTEIN InvestigatorsOral rivaroxaban for symptomatic venous thromboembolismN Engl J Med20103632499251010.1056/NEJMoa1007903 MarluRHodajEParisAAlbaladejoPCrackowskiJPernodGEffect of non-specific agents on anticoagulant activity of dabigatran and rivaroxabanThromb Haemost20121082172241:CAS:528:DC%2BC38Xht1GitbrN10.1160/TH12-03-017922627883 EINSTEIN InvestigatorsOral rivaroxaban for sympotomatic venous thromboembolismN Engl J Med20103632499251010.1056/NEJMoa1007903 MangramAOguntoduODzanduJIs there a difference in efficacy, safety and cost-effectiveness between 3-factor and 4-factor prothrombin complex concentrates among trauma patients on oral anticoagulants?J Crit Care2016332522561:CAS:528:DC%2BC28Xks1yksbg%3D10.1016/j.jcrc.2016.02.01827021851 MillerMPTrujilloTCNordenholzKEPractical considerations in emergency management of bleeding in the setting of target-specific oral anticoagulantsAm J Emerg Med20143237538210.1016/j.ajem.2013.11.04424512886 RomualdiEDonadiniMPAgenoWOral rivaroxaban after symptomatic venous thromboembolism: the continued treatment study (EINSTEIN-extension study)Expert Rev Cardiovasc Ther201198418441:CAS:528:DC%2BC3MXps1ygt78%3D10.1586/erc.11.6221809964 KnepperJHorneDObiAWakefieldTWA systemic update on the state of novel anticoagulants a primer on reversal and bridgingJ Vasc Surg: Venous and Lym Dis20131418426 ConnollySJEzekowitzMDYusufSEikelboomJOldgrenJParekhAPogueJReillyPAThemelesEVarroneJWangSAlingsMXavierDZhuJDiazRLewisBSDariusHDienerHCJoynerCDWallentinLRE-LY Steering Committee and InvestigatorsDabigatran versus warfarin in patients with atrial fibrillationN Engl J Med2009361113911511:CAS:528:DC%2BD1MXhtFOjsLnN10.1056/NEJMoa090556119717844 KörberMLangerEZiemerSMeasurement and reversal of prophylactic and therapeutic peak levels of rivaroxaban: an in vitro studyClin Appl Thromb Hemost20142073574010.1177/107602961349446823832064 ConnollySMillingTEikelboomJANNEXA-4 investigators. Adenanet alfa for acute major bleeding associated with the factor XA inhibitorsN Engl Med2016375113111411:CAS:528:DC%2BC28XhvF2ksrnM10.1056/NEJMoa1607887 ThigenJLLimdiNAReversal of oral anticoagulati Hokusai-VTE Investigators (157_CR14) 2013; 369 A Cuker (157_CR31) 2014; 64 G Agnelli (157_CR13) 2013; 369 J Dinkelaar (157_CR33) 2013; 11 SJ Connolly (157_CR9) 2009; 361 F Akwaa (157_CR27) 2013; 15 157_CR1 BI Eriksson (157_CR2) 2008; 358 DM Siegal (157_CR19) 2013; 34 S Connolly (157_CR47) 2016; 375 D Siegal (157_CR46) 2015; 373 T Riley (157_CR44) 2017; 74 JL Thigen (157_CR26) 2013; 33 S Balla (157_CR30) 2017; 93 MR Patel (157_CR6) 2011; 365 W Mueck (157_CR15) 2014; 53 CV Pollack (157_CR18) 2013; 45 R Marlu (157_CR34) 2012; 108 CB Granger (157_CR10) 2011; 365 ES Eerenberg (157_CR32) 2011; 124 G Pernod (157_CR22) 2013; 106 R Grandhi (157_CR29) 2015; 84 M Körber (157_CR36) 2014; 20 S Kaatz (157_CR21) 2012; 89 W Zhou (157_CR37) 2013; 44 J Knepper (157_CR28) 2013; 1 E Perzborn (157_CR35) 2014; 133 The EINSTEIN-PE Investigators (157_CR8) 2012; 366 W Ageno (157_CR17) 2012; 2 EINSTEIN Investigators (157_CR12) 2010; 363 A Fawole (157_CR24) 2103; 80 S Schulman (157_CR11) 2014; 129 A Mangram (157_CR16) 2016; 33 JS Kalus (157_CR23) 2013; 70 157_CR41 J Gonzva (157_CR42) 2014; 32 157_CR45 A Godier (157_CR39) 2012; 116 AK Kakkar (157_CR3) 2008; 372 T Steiner (157_CR25) 2013; 102 M Levi (157_CR40) 2014; 12 The EINSTEIN Investigators (157_CR7) 2010; 363 MP Miller (157_CR20) 2014; 32 G Mao (157_CR43) 2017; 52 J Ansell (157_CR48) 2014; 371 E Romualdi (157_CR5) 2011; 9 E Perzborn (157_CR38) 2013; 110 MR Lassen (157_CR4) 2008; 358 |
| References_xml | – reference: ZhouWZornMNawrothPButehornUPerzbornEHeitmeierSVeltkampRHemostatic therapy in experimental intracerebral hemorrhage associated with rivaroxabanStroke2013447717781:CAS:528:DC%2BC3sXms1ylt70%3D10.1161/STROKEAHA.112.67523123339956 – reference: MueckWStampfussJKubitzaDBeckaMClinical pharmacokinetic and pharmacodynamic profile of rivaroxabanClin Pharmacokinet20145311161:CAS:528:DC%2BC2cXksVaktw%3D%3D10.1007/s40262-013-0100-723999929 – reference: KnepperJHorneDObiAWakefieldTWA systemic update on the state of novel anticoagulants a primer on reversal and bridgingJ Vasc Surg: Venous and Lym Dis20131418426 – reference: Janssen Pharmaceuticals, Inc. XARELTO® (rivaroxaban) package insert. 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Recent advances in antidotes for direct oral anticoagulants: their arrival is imminent. Can J Cardiol 2014. Accepted manuscript pending publication. – reference: PerzbornEHeitmeierSLauxVBuchmüllerAReversal of rivaroxaban-induced anticoagulation with prothrombin complex concentrate, activated prothrombin complex concentrate and recombinant activated factor VII in vitroThromb Res201413367168110.1016/j.thromres.2014.01.017 – reference: AgenoWGallusASWittkowskyAOral anticoagulant therapy: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice GuidelinesChest20122Supple445e885 – reference: RileyTGauthier-LewisMSanchezCRole of agents for reversing the effects of target-specific oral anticoagulantsAm J Health-Syst Pharm2017742546110.2146/ajhp15081027895055This article looked at the various different mechanisms for reversing oral anticoagulants. 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Both 3-factor and 4-factor PCC did not have an effect on activated partial thromboplastin time (APTT). In summary, this study presents evidence for a more muted response to PCC as compared to the Eerenberg study. – reference: EerenbergESKamphuisenPWSijpkensMKReversal of rivaroxaban and dabigatran by 337 prothrombin complex concentrate. A randomized, placebo-controlled, crossover study in healthy 338 subjectsCirculation2011124157315791:CAS:528:DC%2BC3MXht1GjsLfO10.1161/CIRCULATIONAHA.111.02901721900088This study reports a complete reversal of elevated prothrombin time (PT) and normalization of endogenous thrombin potential (ETP) following administration of 4-factor PCC in humans given rivaroxaban. 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Background: Rivaroxaban is a Xa inhibitor and one of the direct acting oral anticoagulants (DOAC) that currently does not have evidence-based... Purpose of ReviewBackground: Rivaroxaban is a Xa inhibitor and one of the direct acting oral anticoagulants (DOAC) that currently does not have evidence-based... |
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| StartPage | 62 |
| SubjectTerms | Anticoagulants Blood pressure Cardiac arrhythmia Creatinine Drug dosages Emergency medical care Emergency Medicine FDA approval Heart rate Hemorrhage Medicine Medicine & Public Health Ostomy Oxygen saturation Patients Plasma Section Editor Thrombosis Thrombosis (D Slattery |
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| Title | Rivaroxaban-Associated Intraparenchymal Hemorrhage Managed with 4-Factor Prothrombin Complex Concentrate |
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| Volume | 6 |
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