This stuff is not sexy and frankly, it hurts my head. That is all the more reason to do a show on the new landscape of NOAC reversal. We must pursue rather than avoid the subjects we are weak on. But I needed someone far smarter than myself–I needed a EM PharmD. Nobody better to speak about this topic than Nadia Awad. Nadia is associate editor of the Emergency Medicine PharmD Blog. She is an Emergency Medicine Pharmacist at the Robert Wood Johnson University Hospital in New Jersey.

Laboratory Parameters for Monitoring Target-Specific Oral Anticoagulants

Interim Analysis of Idarucizumab: REVERSE-AD

Clinical Experiences Reported in Literature with Idarucizumab Following Approval by FDA

Reviewed on Emergency Medicine PharmD

Fantastic Review on Idarucizumab

Use of Extracorporeal Measures to Expedite Elimination of Dabigatran in the Setting of Life-Threatening Bleeding

Andexanet Alfa

Low-Dose FEIBA for ICH Induced by Factor Xa Inhibitors

Mao G et al. JEM 2016 [Epub ahead of print].

Aripazine (PER977) AKA Ciraparantag

Recommendations for Reversal of ICH Induced by Antithrombotics from Neurocritical Care Society

Excellent reviews on Idarucizumab

Ann Emerg Med 2017;69(5):554

EM Lit of Note

Dosing

Monoclonal antibody

works within minutes

Thrombin time and ECT are best monitoring, aPTT if stone-cold normal prob. rules out Dabi

Package comes with 2 vials

2.5 gm each

5 gms is the initial dose

Give each over 5 minutes

Spike and hang vial

give 2nd vial with 15 minutes of first (no reason not to give immediately)

$4200 for both vials at Janus General

Dabi lasts 12 hours in normal patients, and antidote lasts same ostensibly

Kcentra Studies

RCT of Kcentra (Circulation 2013;128:1234)

Dosing

INR

2-3.9 : 25 units/kg (2500 max)

: 25 units/kg (2500 max) 4-5.9 : 35 units/kg (3500 max)

: 35 units/kg (3500 max) >6: 50 units/kg (5000 max)

Repeat dosing is not recommended, but that doesn't apply to giving fixed dose and then adding on, IMO

Package insert discusses 8.4 ml/minute (210 units/minute) as max rate, but literature supports more rapid administration [cite]19787352[/cite]

Here is a study on the fixed dose use of Kcentra (American Journal of Emergency Medicine 33 (2015) 1213–1218)

More

I'll be doing an upcoming show on reversal-when is it safe, when is it smart

Previous Page on Dabi Reversal

FEIBA is probably safe when given as fixed dose (500 IU for INR < 5 and 1000 IU for >= 5)1

Now on to the Show…

1. Crit Care Med. 2018;46(6):943-948. PubMed] Rowe A, Dietrich S, Phillips J, Foster K, Canter J. Activated Prothrombin Complex Concentrate Versus 4-Factor Prothrombin Complex Concentrate for Vitamin K-Antagonist Reversal.. 2018;46(6):943-948.