56
Management
Table 15. Reversal Agents for Oral Anticoagulants
Idarucizumab Andexanet alfa
Class Humanized monoclonal
antibody fragment binding to
dabigatran and neutralizing
anticoagulation effects
A recombinant modified human
factor Xa protein binding and
sequestering the factor Xa inhibitors
US Food
and Drug
Administration
(FDA)
indications
Reversal of dabigatran effects
• For emergent surgery/
urgent procedures
• Life-threatening or
uncontrolled bleeding
Reversal of apixaban or rivaroxaban
• For life-threatening or
uncontrolled bleeding
Off-label
indications
N/A Edoxaban-associated life-threatening
bleeding
Dosing 5-g (2 separate vials of 2.5 g/
vial) intravenous infusion
over 5 minutes. Additional 5
g may be given if reappearance
of bleeding with elevated
coagulation parameters have
been observed or patients
require second emergent
surgery/procedure and elevated
coagulation parameters
Low-dose regimen: 400-mg bolus at
a target rate of 30 mg/min followed
by 4 mg/min for up to 120 min
High-dose regimen: 800-mg bolus at
a target rate of 30 mg/min followed
by 8 mg/min for up to 120 min
e recommended dosing is based
on apixaban or rivaroxaban, dose,
and time since the patient's last dose
of apixaban or rivaroxaban
Onset Within 5 min Within 2 min
Duration 12–24 h 2 h
Monitoring Coagulation parameters
(activated partial
thromboplastin time [aPTT],
diluted thrombin time,
or ecarin clotting time)
between 12–24 h to assess
redistribution of dabigatran
from peripheral to plasma
Current commercial anti-Xa activity
assays are not suitable for measuring
factor Xa activities aer andexanet
alfa use
Others Risk of serious reactions
(hypoglycemia,
hypophosphatemia, metabolic
acidosis, increase in uric acid,
acute liver failure) in patients
with hereditary fructose
intolerance (due to sorbitol
excipient 4 g in each 5 g of
idarucizumab)
No procoagulant effect based
on endogenous thrombin
potential
No FDA indication for other factor
Xa inhibitors other than apixaban or
rivaroxaban
Andexanet alfa may interfere with
the anticoagulation effect of heparin
US Black Box warning : Serious
and life-threatening adverse
events (arterial and venous
thromboembolism, myocardial
infarction, ischemic stroke, cardiac
arrest, sudden deaths)
Information in table was obtained from manufacturer package inserts.
