Anti-FXa anticoagulation reversal strategies: current evidence 

Thorsten Steiner, MD, PhD, Frankfurt Höchst Clinic, Frankfurt & Heidelberg University, Heidelberg, Germany, discusses current strategies for anti-FXa-associated intracerebral hemorrhage (ICH) management. Although the risk of bleeding whilst using anti-FXa direct oral anticoagulants (DOACs) is substantially lower than with warfarin, the risk remains up to 2% in some real-world data sets and cases are often fatal. Andexanet alfa is currently approved as a specific reversal agent for apixaban or rivaroxaban, when neutralization of their anticoagulant activity is needed due to uncontrolled bleeding. Prothrombin complex concentrate (PCC) can also be used for reversal of anticoagulation induced by vitamin K antagonist therapy in patients presenting with major acute bleeding. However, there is no robust, randomized data assessing the efficacy of PCC in this setting. An ongoing trial aims to shed light on this subject, evaluating the safety and efficacy of andexanet alfa versus usual care in patients with ICH treated with a direct oral or indirect subcutaneous/intravenous anticoagulant (ANNEXA-I; NCT03661528). This interview took place at the ESOC 2022 congress in Lyon, France.