3, 4 However, whereas four-factor prothrombin complex concentrate (4F-PCC) and vitamin K are generally considered the standard of care for reversal of life-threatening bleeding secondary to warfarin (due to warfarin’s availability it has been more extensively studied), reversal of fXa inhibitors in this setting remains controversial due to a lack of high-quality evidence. Compared to warfarin, fXa inhibitors appear to have a lower rate of intracerebral hemorrhage, with annual rates of 0.1–0.2% compared to 0.3–0.6% of patients on warfarin. This is in part because of their ease of use compared to warfarin, which requires frequent laboratory monitoring and dietary modifications and which interacts with numerous medications due to metabolism by a number cytochrome P450 enzymes, posing safety risks. 1, 2 Use of these agents has steadily increased over the last decade. INTRODUCTIONįactor Xa (fXa) inhibitors (eg, apixaban and rivaroxaban) are a class of direct oral anticoagulants that are widely used for a variety of indications, including venous thromboembolism and atrial fibrillation. This multicenter, retrospective cohort study demonstrated that using 4F-PCC for treatment of life-threatening bleeding produced effective hemostasis in patients on fXa inhibitors and warfarin. Thrombotic events were rare in both groups (2% vs 3%). This was consistent across all types of bleeding. Effective hemostasis was similar between groups (79.2% fXa inhibitor group vs 85% warfarin group, p = 0.38). Apixaban (52.1%) and rivaroxaban (45.8%) were the most commonly used fXa inhibitors. Of the 525 patients who had an order for 4F-PCC during the study period, 148 patients met the criteria for inclusion (n = 48 fXa inhibitor group n = 100 warfarin group). The primary endpoint was achievement of hemostatic efficacy after 4F-PCC administration. This was a multicenter, retrospective cohort study at two academic medical centers between January 1, 2014–December 31, 2019, which included patients who presented to the emergency department with a life-threatening bleed necessitating anticoagulation reversal with 4F-PCC. The purpose of this study was to determine the hemostatic efficacy of four-factor prothrombin complex concentrate (4F-PCC) for the reversal of fXa inhibitors compared to warfarin for life-threatening bleeding.
Factor Xa (fXa) inhibitor reversal for life-threatening bleeding is controversial due to a lack of high-quality evidence.
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