A UK-wide analysis of the use of reversal agents in 198 patients on direct oral anticoagulants prior to urgent procedures.

BACKGROUND

Direct oral anticoagulants (DOACs) are widely prescribed but present challenges when patients require urgent invasive procedures. While idarucizumab is licensed for preprocedural reversal of dabigatran, 4-factor prothrombin complex concentrates (4F-PCCs) are often used off-label for oral factor (F)Xa inhibitors.

OBJECTIVES

We aimed to describe real-world UK use of reversal agents prior to urgent procedures.

METHODS

We conducted a UK-wide audit of adults receiving andexanet alfa, idarucizumab, or 4F-PCC to reverse apixaban, dabigatran, edoxaban, or rivaroxaban, before urgent procedures between October 2020 and June 2023. Data were collected by members of HaemSTAR, a UK-wide network led by hematology resident doctors. Primary outcomes were (1) receipt of reversal ≤24 hours before procedure and (2) adherence to recommended dosing. Secondary outcomes included procedural bleeding risk, 90-day mortality, and 30-day thrombosis rate.

RESULTS

Data were collected on 198 patients, with 48% undergoing high-risk procedures. Median time from reversal to procedure was 1.6 hours and 76% took place within 24 hours. 4F-PCC was used in 87%, idarucizumab in 8%, and andexanet alfa in 5%. Tranexamic acid was administered in 20%, 90-day mortality was 24%, and thromboembolic events occurred in 3%, all following 4F-PCC.

CONCLUSION

Reversal agents are frequently used prior to urgent procedures in direct oral anticoagulant-treated patients, including for low-risk interventions. There is limited evidence to support the off-label use of 4F-PCC; the risks, benefits, and cost effectiveness are uncertain. Delays to intervention, low use of tranexamic acid, and infrequent drug-level testing highlight opportunities to improve clinical workflows and inform future trials.