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North America anticoagulation forum guidance on reversal of direct oral anticoagulants

      The direct oral anticoagulants (DOACs) (apixaban, rivaroxaban, betrixaban, edoxaban and dabigatran) have gradually replaced vitamin K antagonists (VKAs) as the mainstay anticoagulation therapy. However, lack of specific reversal agents has been consistently raised as a concern since the introduction of the DOACs. Major bleeding and invasive procedures are common clinical settings where DOAC reversal may be required; further a high frequency of co-morbid conditions makes it likely that patients treated with DOACs will require such interruptions of their therapy. Currently only idarucizumab (Praxbind, Boehringer Ingelheim) and andexanet alfa (Andexxa, Portola Phamaceuticals) are approved by regulatory agents as specific DOAC reversal agents [
      • Idaruczumab prescribing information
      , ]. Non-specific prohemostatic agents such as prothrombin complex concentrate (PCC) (multiple brands) and activated prothrombin complex (APCC) (FEIBA [anti-inhibitor coagulant complex], TAKEDA Pharmaceutical Company) have also been widely used “off-label” for DOAC reversal [
      • Siegal D.M.
      • Movilla R.
      • Siddiqui R.
      • Barty R.
      • Crowther M.A.
      • Heddle N.M.
      Non-specific hemostatic agents (PCC, aPCC, rVIIa) for reversal of direct oral anticoagulant effect in patients with major bleeding complications: a retrospective review.
      ,
      • Prothrombin complex concentrate prescribing information
      ,
      • Activated prothrombin complex prescribing information
      ].
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