DOAC Reversal

Direct oral anticoagulants (DOACs) include factor Xa inhibitors (rivaroxaban, apixaban, edoxaban) and the direct thrombin (factor IIa) inhibitor dabigatran. Unlike warfarin, DOACs have predictable pharmacokinetics that typically do not require routine laboratory monitoring. However, when life-threatening bleeding or emergent surgery occurs, rapid reversal is critical. Dabigatran reversal: Idarucizumab (Praxbind) is a humanized monoclonal antibody fragment (Fab) that binds dabigatran with ~350 times greater affinity than thrombin, effectively neutralizing ALL circulating dabigatran within minutes. Dose: 5 grams IV (two 2.5g vials) administered as two consecutive infusions. The RE-VERSE AD trial demonstrated complete reversal in 88% of patients within 4 hours. Idarucizumab is SPECIFIC to dabigatran — it does NOT reverse factor Xa inhibitors. Factor Xa inhibitor reversal: Andexanet alfa (Andexxa) is a modified recombinant factor Xa decoy protein that binds and sequesters factor Xa inhibitors (rivaroxaban, apixaban, and LMWH). It has no intrinsic procoagulant activity because the active site serine has been replaced with alanine. Dosing depends on the specific Xa inhibitor and time since last dose (low-dose vs. high-dose regimen). The ANNEXA-4 trial showed hemostatic efficacy in ~82% of patients....