Case Resolution and the Evolution of Anticoagulation Reversal
Your patient receives idarucizumab early during his emergency department stay, and despite a somewhat rocky course, he survives his surgery for a ruptured liver, thanks to the specific reversal agent for dabigatran and due to the good fortune that he was taking the one DOAC with a reversal agent.
Explore This IssueACEP Now: Vol 38 – No 01 – January 2019
In more recent developments, the first Xa DOAC reversal agent, andexanet alfa (Andexxa), was approved by the FDA in May 2018. It reverses both rivaroxaban (Xarelto) and apixaban (Eliquis), but the indications do not cover edoxaban (Savaysa) and betrixaban (Bevyxxa).
Depending on the dose of rivaroxaban or apixaban being taken, either a low-dose or high-dose regimen of andexanet alfa is advised. The Medical Letter indicated that the drug had very limited availability (10 hospitals had it at the time of publication), but supplies are expected to increase in early 2019.2 The cost is $49,500 for the high dose and half that for the low dose.
Dr. Bukata is medical director for the The Center for Medical Education and adjunct clinical professor of emergency medicine at LAC+USC Medical Center in Los Angeles.
- Buchheit J, Reddy P, Connors JM. Idarucizumab (Praxbind) formulary review. Crit Pathw Cardiol. 2016;15(3):77-81.
- Andexxa—an antidote for apixaban and rivaroxaban. Med Lett Drugs Ther. 2018;60(1549):99-101.