Andexanet Alfa Versus 4F-PCC for Direct Anticoagulation Reversal in Intracranial Hemorrhage: A Quality Improvement (QI) Analysis
Audrey Huang1, Jenny Yang1, William Liu1, Deepika Dilip1, Nimrod Gozum1, Gular Mammadli2, Colleen Bond3, Hasit Mehta4, Stephan Mayer2
1School of Medicine, New York Medical College, 2Neurology, 3Pharmacy, 4Neuroradiology, Westchester Medical Center
Objective:
To compare the effectiveness of andexanet alfa and 4F-PCC in clinical practice at a single institution.
Background:
Anticoagulation reversal is crucial for managing DOAC-related intracranial hemorrhage. We conducted a QI project to evaluate the impact of a streamlined DOAC reversal protocol on patient outcomes and determine the comparative effectiveness of the primary reversal agents used.
Design/Methods:
We retrospectively analyzed 73 patients at a single institution who were on a factor Xa inhibitor at time of admission, had a head CT on admission demonstrating intracranial hemorrhage, and received 4F-PCC or andexanet alfa between 10/1/2020 and 10/1/2022. Hemorrhage volume was measured using computerized planimetry before and after reversal. Clinically significant hemorrhage expansion was defined as volume increase of ≥6 mL or ≥33%. Other outcomes included change in hemorrhage volume, neurological deterioration (2-point drop in GCS or 5-point NIHSS increase), and thrombotic complications. Statistical tests included rank sum, t-test, or two-proportion tests.
Results:
Among the 73 patients evaluated (median age = 78, 65% male), 50 were reversed with 4F-PCC and 23 with andexanet alfa. 57 patients were on apixaban, 14 on rivaroxaban, and 1 on fondaparinux. Baseline ICH volumes and door-to-needle times were comparable between both groups. Patients reversed with 4F-PCC had a median hemorrhage volume change of +2.4% compared to -0.2% for andexanet alfa (difference of 2.6 percentage points; 95% confidence interval [CI], [-17.56, 19.35]; p = 0.63). Discharge outcomes, clinically significant hemorrhage expansion, and neurologic deterioration in both 4F-PCC and andexanet alfa treated patients were similar. Thromboembolic complications were more common with 4F-PCC (6% versus 0%, P=0.57), though not statistically significant. Overall, no significant differences in clinical outcomes were found between the two treatments.
Conclusions:
The findings of our analysis indicate that 4F-PCC and andexanet alfa are similarly effective in DOAC reversal for patients with ICH at our institution.
Disclaimer: Abstracts were not reviewed by Neurology® and do not reflect the views of Neurology® editors or staff.