Abstract Number: PB0040
Meeting: ISTH 2021 Congress
Background: Inconsistencies exist in current guideline recommendations of oral anticoagulant reversal.
Aims: This study aims to evaluate current practice patterns and factors influencing treatment decisions when reversing oral anticoagulants.
Methods: A three-section survey with 27 closed and open-ended questions was electronically distributed to anticoagulation specialists of the Anticoagulation Forum. Questions were designed to capture practice trends in urgent or emergent reversals of warfarin, factor-Xa inhibitors, and factor-IIa inhibitors. Continuous and categorical data were analyzed to generate descriptive statistics and compared with current guideline recommendations. Data for open-ended questions were summarized by thematic categories.
Results: 173 responses were collected, 77.8% were pharmacists, 76.1% were direct patient care providers, and 84.3% were based in the US. Among various reversal agents, vitamin K (91.3%), activated charcoal (80.4%), and plasma (72.8%) were mostly reported as on formulary without restrictions; 87.0% reported four-factor prothrombin complex concentrate (4F-PCC) on formulary either with (52.2%) or without (34.8%) restrictions. Although 4F-PCC and andexanet alfa are suggested by current guidelines as first-line agents to reverse warfarin and factor-Xa inhibitors, respectively, vitamin K (98.8%) was the most commonly used reversal agent for warfarin and 4F-PCC (71.6%) for factor-Xa inhibitors. Weight-based dosing for 4F-PCC, as recommended by guidelines, is utilized only in 59.4%, 41.2%, and 44.4% of warfarin, factor-Xa inhibitor, and factor-IIa inhibitor reversals, respectively. Cost, efficacy, and safety of 4F-PCC relative to other reversal agents were identified as both top facilitators and barriers for 4F-PCC adoption in practice. The majority of the respondents’ institutions (90.2%) utilized a guideline or protocol for urgent or emergent reversal of oral anticoagulants.
|Table 1: First-line Agents and 4F-PCC Dosages used in Oral Anticoagulant Reversal*
|Reversal of warfarin
|Reversal of factor-Xa inhibitors
|Reversal of factor-IIa inhibitors
|First-line agents||Vitamin K (98.8%)
Activated charcoal (6.0%)
Recombinant factor-VIIa (2.4%)
Activated Charcoal (28.4%)
Andexanet Alfa (19.75%)
Activated Charcoal (23.8%)
||Weight-based dosage according to INR (59.4%)
Fixed dose: 1,500 units for all (15.6%)
Fixed dose: 1,500 units for ICH, 1,000 units for all other (10.9%)
Fixed dose: 1,000 units for all (3.1%)
Fixed dose: 500 units for all (1.6%)
|Weight-based dosage 50 units/kg (41.2%)
Fixed dosing: 2000 units for all (20.6%)
Weight-based dosage 25 units/kg (8.8%)
Fixed dose: 1,500 units for ICH, 1,000 units for all other (7.4%)
Fixed dose: 500 units for all (2.9%)
Fixed dose: 1,500 units for all (1.5%)
Fixed dose: 1,000 units for all 1.5%)
|Weight-based dosage 50 units/kg (44.4%)
Fixed dose: 1,500 units for ICH, 1,000 units for all other (14.8%)
Fixed dose: 1,500 units for all (11.1%)
Fixed dose: 1,000 units for all (3.7%)
Fixed dose: 500 units for all (3.7%)
|* More than one option could be selected by the respondents
** Other dosages for warfarin reversal: weight-based doses for ICH and fixed doses for other indications, other weight-based dosages according to INR, or fixed dosages with a different dose
*** Other dosages for factor-Xa reversal: weight-based doses for ICH and fixed doses for others, or other weight-based dosages according to INR
**** Other dosages for factor-IIa reversal: weight-based dosage 25 units/kg, or 2000 units for all
Conclusions: Our findings revealed that guideline recommendations for reversal of warfarin and factor-Xa inhibitors are not followed by a sizable proportion of institutions. Additional studies with a larger sample size are needed to confirm evolving reversal practice patterns.
To cite this abstract in AMA style:Deng H, DiDomenico R, Nutescu E. Reversal of Oral Anticoagulants: A Survey of Contemporary Practice Trends (ReACT) [abstract]. Res Pract Thromb Haemost. 2021; 5 (Suppl 2). https://abstracts.isth.org/abstract/reversal-of-oral-anticoagulants-a-survey-of-contemporary-practice-trends-react/. Accessed November 28, 2022.
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