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March 2023 Quick Question: Apixaban Reversal

Our March 2023 Quick Question asked, “Which reversal agent is effective in managing apixaban overdose?” Our 45 respondents chose:

  1. rFVIIa [NovoSeven]: 4 [9%]
  2. Andexanet alfa: 28 [62%]
  3. Idarucizumab: 5 [11%]
  4. Vitamin K: 6 [13%]
  5. FFP: 2 [5%]

Before direct reversal agents became available, DOAC overdose-related bleeding was treated by attempting to absorb undigested anticoagulant from the stomach using activated charcoal, diuresis, dialysis, controlling fibrinolysis with tranexamic acid, and in severe bleeding, using a bypassing agent such as FEIBA or rFVIIa. Frozen plasma, once called “fresh frozen plasma” [FFP] was not recommended as it is minimally effective and could result in transfusion-associated circulatory overload [TACO]. The bypassing agents may still be considered when direct reversal agents are unavailable. See Alikhan R, Rayment R, Keeling D, et al. The acute management of hemorrhage, surgery and overdose in patients receiving dabigatran. Emerg Med J 2014;31: 163–168.

As the majority of our respondents indicated, andexanet alfa [Andexxa] is the reversal agent for the anti-Xa anticoagulants rivaroxaban and apixaban, and idarucizumab [Praxbind] reverses the antithrombin dabigatran. Vitamin K remains in demand when bleeding is the result of warfarin, the commonly used vitamin K antagonist, overdose.

Thanks to all our respondents.

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