Warfarin studies
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Steiner, 2016
4040 Steiner T, Poli S, Griebe M, et al. Fresh frozen plasma versus prothrombin complex concentrate in patients with intracranial haemorrhage related to vitamin K antagonists (INCH): a randomised trial. Lancet Neurol. 2016;15:566-73.
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Prospective, randomized, open-label, blinded-endpoint clinical study |
50 VKA-ICH patients |
4F-PCC vs FFP |
67% of PCC group vs 9% of FFP group, p = 0.0003 |
Goldstein, 2015
3030 Goldstein JN, Refaai MA, Milling TJ, et al. Four-factor prothrombin complex concentrate versus plasma for rapid vitamin K antagonist reversal in patients needing urgent surgical or invasive interventions: a phase 3b, open-label, noninferiority, randomised trial. Lancet. 2015;385(9982):2077-87.
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Prospective, randomized, open-label, clinical study |
181 VKA-treated patients needing urgent surgical or invasive procedures |
4F-PCC vs FFP |
90% of the PCC group vs 75% of the FFP group. |
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Rapid INR reduction in 55% of the PCC group vs 10% of the FFP group |
Kerebel, 2012
3737 Kerebel D, Joly LM, Honnart D, et al. A French multicenter randomised trial comparing two dose-regimens of prothrombin complex concentrates in urgent anticoagulation reversal. Crit Care. 2013;17:R4.
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Prospective, randomized, open-label study |
59 VKA-associated intracranial hemorrhage |
4F-PCC |
40 IU.kg-1 of 4F-PCC significantly decreased the INR compared to that of the 25 IU.kg-1 group (p = 0.001). |
Demeyere, 2010
5555 Demeyere R, Gillardin S, Arnout J, et al. Comparison of fresh frozen plasma and prothrombin complex concentrate for the reversal of anticoagulants in patients undergoing cardiopulmonary bypass surgery: a randomized study. Vox Sang. 2010;99:251-60.
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Prospective, randomized, open-label, clinical study |
40 cardiac surgery patients |
4F-PCC vs FFP |
Faster target INR with PCC (p = 0.007), and less additional dose (p < 0.001) |
Burburry 2011
3333 Burbury KL, Milner A, Snooks B, et al. Short-term warfarin reversal for elective surgery using low-dose intravenous vitamin K: safe, reliable and convenient. Br J Haematol. 2011;154:626-34.
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Prospective single-arm clinical study |
178 presurgical patients under warfarin |
Vitamin K |
94% with INR levels 1.5 or less on the day of surgery |
Chausson, 2018
4141 Chausson N, Soumah D, Aghasaryan M, et al. Reversal of Vitamin K Antagonist Therapy Before Thrombolysis for Acute Ischemic Stroke. Stroke. 2018;49:2526-8.
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Pilot clinical study |
26 acute ischemic stroke patients |
4F-PCC and vitamin K |
No symptomatic ICH or thrombotic events |
Pautas, 2011
3434 Pautas E, Peyron I, Bouhadiba S, et al. Reversal of over anticoagulation in very elderly hospitalized patients with an INR above 5.0: 24-hour INR response after vitamin K administration. Am J Med. 2011;124:527-33.
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Prospective, observational study |
239 elderly hospitalized patients with over-anticoagulation |
Vitamin K |
Decrease in INR levels, achieving 2.7 ± 1.3 on Day 1 (p < .0001) |
Bhatia, 2010
3232 Bhatia M, Talawadekar G, Parihar S, et al. An audit of the role of vitamin K in the reversal of International Normalised Ratio (INR) in patients undergoing surgery for hip fracture. Ann R Coll Surg Engl. 2010;92:473-6.
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Prospective, observational study |
45 proximal hip fracture patients |
Vitamin K |
INR levels decreased to 1.5 or less in 2 days (mean, 38 h; range, 15-64 h |
Rimsans, 2018
4242 Rimsans J, Levesque A, Lyons E, et al. Four-factor prothrombin complex concentrate for warfarin reversal in patients with left ventricular assist devices. J Thromb Thrombolysis. 2018;46:180-5.
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Prospective, observational study |
37 patients with continuous flow left ventricular assistive devices |
4F-PCC |
Efficient reversal, no case of thromboembolism, mean INR from 2.9 to 1.7 (p < 0.0001) |
Yank, 2011
6262 Yank V, Tuohy CV, Logan AC, et al. Systematic Review: Benefits and Harms of In-Hospital Use of Recombinant Factor VIIa for Off-Label Indications. Ann Intern Med. 2011;154:529-40.
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Systematic review |
64 studies included |
rFVIIa vs placebo or usual care |
No mortality reduction Increased thromboembolism risk |
Dentalli, 2011
3838 Dentali F, Marchesi C, Giorgi Pierfranceschi M, et al. Safety of prothrombin complex concentrates for rapid anticoagulation reversal of vitamin K antagonists. A meta-analysis. Thromb Haemost. 2011;106:429-38.
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Systematic review |
27 studies included |
3F-PCC and 4F-PCC |
Incidence of thromboembolic complications: 1.8% (95% CI 1.0-3.0) with 4F-PCC and 0.7% (95% CI 0.0-2.4) with 3F-PCC |
Matino, 2015
6363 Matino D, Makris M, Dwan K, et al. Recombinant factor VIIa concentrate versus plasma-derived concentrates for treating acute bleeding episodes in people with haemophilia and inhibitors. Cochrane Database Syst Rev. 2015;:CD004449.
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Systematic review |
2 studies, with 69 patients |
rFVIIa vs aPCC |
Similar hemostatic effect |
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No increase in thromboembolic risk |
Chai-Adisaksopha, 2016
3535 Chai-Adisaksopha C, Hillis C, Siegal DM, et al. Prothrombin complex concentrates versus fresh frozen plasma for warfarin reversal. A systematic review and meta-analysis. Thromb Haemost. 2016;116:879-90.
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Systematic review |
13 studies included |
PCC vs FFP |
PCC: significant reduction in mortality, more rapid INR reduction, less volume overload. No statistically significant difference in VTE risk |
Milling, 2016
3939 Milling TJ, Refaai MA, Goldstein JN, et al. Thromboembolic Events After Vitamin K Antagonist Reversal With 4-Factor Prothrombin Complex Concentrate: Exploratory Analyses of Two Randomized, Plasma-Controlled Studies. Ann Emerg Med. 2016;67:96-105.e5.
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Post hoc analyses of pooled data |
2 randomized trials, with 388 patients |
4F-PCC vs FFP |
Incidence of thromboembolic complications: 7.3% in the 4F-PCC group and 7.1% in the FFP group |
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Risk difference 0.2%; 95% CI-5.5% to 6.0% |
Barton, 2018
6060 Barton CA, Hom M, Johnson NB, et al. Protocolized warfarin reversal with 4-factor prothrombin complex concentrate versus 3-factor prothrombin complex concentrate with recombinant factor VIIa. Am J Surg. 2018;215:775-9.
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Retrospective cohort study |
195 patients with life-threatening bleeding |
4F-PCC vs 3F-PCC and rFVIIa |
Faster and longer duration of reversal with 4F-PCC (p < 0.01) |
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Higher mortality and VTE with 3F-PCC and rFVIIa (p < 0.01) |
Rowe, 2016
5151 Rowe AS, Mahbubani PS, Bucklin MH, et al. Activated Prothrombin Complex Concentrate versus Plasma for Reversal of Warfarin-Associated Hemorrhage. Pharmacotherapy. 2016;36:1132-7.
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Retrospective cohort study |
158 patients with warfarin-associated hemorrhage |
aPCC vs 4F-PCC |
No difference in effectiveness and safety between treatments |
Holt, 2018
4848 Holt T, Taylor S, Abraham P, et al. Three- versus four-factor prothrombin complex concentrate for the reversal of warfarin-induced bleeding. Int J Crit Illn Inj Sci. 2018;8:36-40.
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Retrospective cohort study |
134 patients with warfarin-associated bleeding |
4F-PCC vs 3F-PCC |
INR normalization: 84.2% with 4F-PCC vs. 51.9% with 3F-PCC, p = 0.0001 |
Mattisson, 2018
4444 Mattisson L, Lapidus LJ, Enocson A. Is fast reversal and early surgery (within 24 h) in patients on warfarin medication with trochanteric hip fractures safe? A case-control study. BMC Musculoskelet Disord. 2018;19:203-10.
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Retrospective case-control study |
Patients with hip fractures: 99 taking warfarin and 99 controls |
4F-PCC and vitamin K |
No significant differences in blood loss, adverse events or mortality |
Hedges, 2015
4545 Hedges A, Coons JC, Saul M, et al. Clinical effectiveness and safety outcomes associated with prothrombin complex concentrates. J Thromb Thrombolysis. 2015;42:1-5.
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Retrospective chart review |
193 patients taking warfarin and DOACs |
PCC, 4F-PCC |
65.8% achieved target INR in 8.03 h (IQR 3.38-34.07) |
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4.1% with acute VTE |
Voils, 2015
4949 Voils SA, Holder MC, Premraj S, et al. Comparative effectiveness of 3- versus 4-factor prothrombin complex concentrate for emergent warfarin reversal. Thromb Res. 2015;136:595-8.
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Retrospective chart review |
165 patients requiring emergency reversal |
4F-PCC vs 3F-PCC |
No difference in VTE events. Higher mortality in 3F-PCC group (p < 0.01) |
Mehringer, 2018
6161 Mehringer SL, Klick Z, Bain J, et al. Activated Factor 7 Versus 4-Factor Prothrombin Complex Concentrate for Critical Bleeding Post-Cardiac Surgery. Ann Pharmacother. 2018;52:533-7.
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Retrospective chart review |
129 cardiac surgery patients with significant bleeding |
rFVIIa vs 4F-PCC |
No difference in bleeding, thromboembolic events, or re-exploration |
Chapman, 2014
5858 Chapman SA, Irwin ED, Abou-Karam NM, et al. Comparison of 3-Factor Prothrombin Complex Concentrate and Low-Dose Recombinant Factor VIIa for Warfarin Reversal. World J Emerg Surg. 2014;9:27-34.
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Retrospective chart review |
106 patients needing emergency reversal |
3F-PCC vs low-dose rFVIIa |
71.9% rFVIIa patients achieved target INR vs. 33.8% 3F-PCC, p = 0.001 No difference in VTE risk |
Carothers, 2018
5050 Carothers C, Giancarelli A, Ibrahim J, et al. Activated prothrombin complex concentrate for warfarin reversal in traumatic intracranial hemorrhage. J Surg Res. 2018;223:183-7.
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Retrospective chart review |
89 patients with traumatic ICH |
aPCC vs FFP |
Reversal achieved in 90.3% with aPCC vs 69.7% with FFP, p = 0.029 |
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Faster reversal with aPCC, p = 0.003. No difference in mortality and VTE risk |
Woo, 2014
5757 Woo CH, Patel N, Conel C, et al. Rapid warfarin reversal in the setting of intracranial hemorrhage: a comparison of plasma, recombinant activated factor VII and prothrombin complex concentrate. World Neurosurg. 2014;81:110-5.
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Retrospective chart review |
63 VKA-ICH patients |
FFP vs rFVIIa vs PCC |
PCC and rFVIIa reached target INR faster than FFP (p < 0.05). |
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More rebound with FFP and rFVIIa (p = 0.001) |
Sarode, 2012
5959 Sarode R, Matevosyan K, Bhagat R, et al. Rapid warfarin reversal: a 3-factor prothrombin complex concentrate and recombinant factor VIIa cocktail for intracerebral hemorrhage. J Neurosurg. 2012;116:491-7.
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Retrospective chart review |
46 VKA-ICH patients |
3F-PCC and rFVIIa |
Rapid and effective reversal |
Astrup, 2018
4747 Astrup G, Sarangarm P, Burnett A. Fixed dose 4-factor prothrombin complex concentrate for the emergent reversal of warfarin: a retrospective analysis. J Thromb Thrombolysis. 2018;45:300-5.
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Retrospective chart review |
37 patients with urgent reversal |
Single fixed dose of 1500 IU of 4F-PCC |
75% achieved INR ≤ 1.5 |
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100% achieved INR ≤ 2 |
Mačiukaitienė, 2018
4343 Mačiukaitienė J, Bilskienė D, Tamašauskas A, et al. Prothrombin Complex Concentrate for Warfarin-Associated Intracranial Bleeding in Neurosurgical Patients: A Single-Center Experience. Medicina. 2018;54:22-31.
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Retrospective chart review |
35 VKA-ICH requiring urgent neurosurgical procedures |
4F-PCC and vitamin K |
Decrease in INR (p < 0.01), PT (p < 0.01), and PTT (p = 0.02), no adverse effect |
Scott, 2018
4646 Scott R, Kersten B, Basior J, et al. Evaluation of Fixed-Dose Four-Factor Prothrombin Complex Concentrate for Emergent Warfarin Reversal in Patients with Intracranial Hemorrhage. J Emerg Med. 2018;54:861-6.
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Retrospective cohort study |
31 VKA-ICH patients |
4F-PCC |
No significant difference between the fixed and weight-based doses of 4F-PCC |
DOACs studies
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Pollack, 2017
9191 Stangier J, Rathgen K, Stähle H, et al. Influence of renal impairment on the pharmacokinetics and pharmacodynamics of oral dabigatran etexilate: an open-label, parallel-group, single-center study. Clin Pharmacokinet. 2010;49:259-68.
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Multicenter, prospective, open-label study |
503 patients under dabigatran with bleeding or urgent surgical intervention |
Idarucizumab |
100% of median maximum percentage reversal |
Siegal, 2015
6868 Siegal DM, Curnutte JT, Connolly SJ, et al. Andexanet Alfa for the Reversal of Factor Xa Inhibitor Activity. N Engl J Med. 2015;373:2413-24.
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Prospective, randomized, double-blind, placebo-controlled study |
101 healthy older volunteers taking Xa inhibitors |
Andexanet alpha |
Efficient reversal within minutes after administration |
Connolly, 20196
6969 Connolly SJ, Crowther M, Eikelboom JW, et al. Full Study Report of Andexanet Alfa for Bleeding Associated with Factor Xa Inhibitors. N Engl J Med. 2019;380:1326-35.
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Prospective, open-label, single-group study |
352 patients who had acute major bleeding within 18 hours after administration of a factor Xa inhibitor |
Andexanet alpha |
92% reduction in anti-factor Xa activity. |
Eerenberg, 2011
7171 Cuker A, Burnett A, Triller D, et al. Reversal of direct oral anticoagulants: Guidance from the Anticoagulation Forum. Am J Hematol. 2019;94:697-709.
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Prospective, randomized, double-blind, placebo-controlled study |
12 healthy volunteers taking rivaroxaban or dabigatran |
4F-PCC |
Immediate and complete reversal of rivaroxaban anticoagulation activity (p = 0.0001) |
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No effect on dabigatran |
da Luz, 2017
7272 Eerenberg ES, Kamphuisen PW, Sijpkens MK, et al. Reversal of rivaroxaban and dabigatran by prothrombin complex concentrate a randomized, placebo-controlled, crossover study in healthy subjects. Circulation. 2011;124:1573-9.
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Systematic review and meta-analysis |
12 studies included DOAC reversal |
PCC |
PCC reversed the prothrombin time and endogenous thrombin potential (p < 0.01) |
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Andexanet alfa |
Andexanet alfa, idarucizumab: completed reversal was achieved |
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Idarucizumab |
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Piran, 2019
8080 Grandhi R, Newman WC, Zhang X, et al. Administration of 4-factor prothrombin complex concentrate as an antidote for intracranial bleeding in patients taking direct factor Xa inhibitors. World Neurosurg. 2015;84:1956-61.
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Systematic review and meta-analysis |
10 case series with 340 patients presenting direct Xa inhibitor-related major bleeding |
4F-PCC |
Effective management of bleeding: 0.69 (95% CI 0.61-0.76). |
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Mortality: 0.16 (95% CI: 0.07-0.26), VTE: 0.04 (95% CI: 0.01-0.08) |
Majeed, 2017
7474 Piran S, Gabriel C, Schulman S. Prothrombin complex concentrate for reversal of direct factor Xa inhibitors prior to emergency surgery or invasive procedure: a retrospective study. J Thromb Thrombolysis. 2018;45:486-95.
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Prospective cohort study |
84 patients under Xa inhibitors presenting major bleeding events |
4F-PCC |
Efficacy in 69.1% of patients |
Dybdahl, 2019
7979 Tao J, Bukanova EN, Akhtar S. Safety of 4-factor prothrombin complex concentrate (4F-PCC) for emergent reversal of factor Xa inhibitors. J Intensive Care. 2018;6:34-40.
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Retrospective cohort study |
62 patients taking factor Xa inhibitors with traumatic ICH |
4F-PCC vs no reversal |
No difference in mortality, functional recovery, hospitalization duration or thromboembolic events |
Allison, 2018
3636 Allison TA, Lin PJ, Gass JA, et al. Evaluation of the Use of Low-Dose 4-Factor Prothrombin Complex Concentrate in the Reversal of Direct Oral Anticoagulants in Bleeding Patients. J Intensive Care Med. 2020;35:903-8.
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Retrospective, observational study |
33 patients taking Xa inhibitors with major bleeding requiring emergent reversal |
4F-PCC |
83.8% achieved hemostasis |
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No VTE event |
Green, 2019
8282 Piran S, Khatib R, Schulman S, et al. Management of direct factor Xa inhibitor-related major bleeding with prothrombin complex concentrate: a meta-analysis. Blood Adv. 2019;3:158-67.
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Retrospective chart review |
421 patients with DOAC-related major bleeding |
4F-PCC |
Low-dose PCC: lower mortality (hazard ratio: 0.5; 95% CI: 0.02-1.19; p = 0.07) |
Piran, 2018
7373 da Luz LT, Marchand M, Nascimento B, et al. Efficacy and safety of the drugs used to reverse direct oral anticoagulants: a systematic review and meta-analysis. Transfusion. 2017;57:1834-46.
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Retrospective chart review |
247 Xa inhibitors patients undergoing emergency surgery or an invasive procedure |
4F-PCC |
85.7% achieved good hemostasis. No VTE events occurred. |
Dager, 2019
8181 Dybdahl D, Walliser G, Chance Spalding M, et al. Four-factor prothrombin complex concentrate for the reversal of factor Xa inhibitors for traumatic intracranial hemorrhage. Am J Emerg Med. 2019;37:1907-11.
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Retrospective analysis |
64 patients with DOAC-related bleeding |
aPCC |
Thromboembolic complications: 8%. |
Tao, 2018
7777 Sheikh-Taha M. Treatment of apixaban- and rivaroxaban-associated major bleeding using 4-factor prothrombin complex concentrate. Intern Emerg Med. 2019;14:265-9.
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Retrospective chart review |
43 patients under Xa inhibitors needing emergency reversal |
4F-PCC |
VTE: 2.1%, 95% CI: 0.1-12.3 |
Harrison, 2018
7676 Schulman S, Gross PL, Ritchie B, et al. Prothrombin complex concentrate for major bleeding on factor Xa inhibitors: a prospective cohort study. Thromb Haemost. 2018;118:842-51.
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Retrospective chart review |
42 factor Xa inhibitor anticoagulant and VKA-ICH |
4F-PCC |
No difference in the mortality, rates of hemorrhagic expansion, VTE, between Xa inhibitors and VKA patients receiving 4F-PCC |
Engelbart, 2019
8484 Green L, Tan J, Antoniou S, et al. Haematological management of major bleeding associated with direct oral anticoagulants- UK experience. Br J Haematol. 2019;185:514-22.
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Retrospective case series study |
42 patients with emergent reversal of DOAC for life-threatening hemorrhage or urgent surgical interventions |
aPCC |
Thrombotic events: 10%; hemorrhage progression: 10%; mortality: 29% |
Sheikh-Taha, 2019
7575 Majeed A, Ågren A, Holmström M, et al. Management of rivaroxaban- or apixaban-associated major bleeding with prothrombin complex concentrate: a cohort study. Blood. 2017;130:1706-12.
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Retrospective chart review |
29 patients taking factor Xa inhibitors with major bleeding |
4F-PCC |
72.4% patients achieved clinical hemostasis |
Grandhi, 2015
7878 Harrison SK, Garrett JS, Kohman KN, et al. Comparison of outcomes in patients with intracranial hemorrhage on factor Xa inhibitors versus vitamin K antagonists treated with 4-factor prothrombin complex concentrate. BUMC Proc. 2018;31:153-6.
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Retrospective chart review |
18 patients with Xa inhibitors-ICH |
4F-PCC |
No hemorrhagic complications after surgery. |
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One VTE event |
Senger, 2016
8181 Dybdahl D, Walliser G, Chance Spalding M, et al. Four-factor prothrombin complex concentrate for the reversal of factor Xa inhibitors for traumatic intracranial hemorrhage. Am J Emerg Med. 2019;37:1907-11.
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Retrospective chart review |
17 patients under dabigatran or rivaroxaban with ICH |
4F-PCC |
Of 6 patients who underwent immediate surgery, 50% presented severe intraoperative hemorrhage |
Dibu, 2016
8787 Dager WE, Roberts AJ, Nishijima DK. Effect of low and moderate dose FEIBA to reverse major bleeding in patients on direct oral anticoagulants. Thromb Res. 2019;173:71-6.
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Prospective observational study |
127 patients with spontaneous ICH under DOAC: 5 patients receiving aPCC |
aPCC |
No ICH expansion, hemorrhagic, or thrombotic complications |
Schulman, 2014
9292 Khadzhynov D, Wagner F, Formella S, et al. Effective elimination of dabigatran by haemodialysis. A phase I single-center study in patients with end-stage renal disease. Thromb Haemost. 2013;109:596-605.
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Case series |
4 patients under DOAC with a major bleeding episode |
aPCC |
Recovery, no effect on hemostatic parameters |