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2013 ; 17
(3
): 230
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Clinical review: Clinical management of new oral anticoagulants: a structured
review with emphasis on the reversal of bleeding complications
#MMPMID23806169
Lazo-Langner A
; Lang ES
; Douketis J
Crit Care
2013[Jun]; 17
(3
): 230
PMID23806169
show ga
New oral anticoagulants, including dabigatran, rivaroxaban, and apixaban, have
been recently approved for primary and secondary prophylaxis of thromboembolic
conditions. However, there is no clear strategy for managing and reversing their
anticoagulant effects. We aimed to summarize the available evidence for clinical
management and reversal of bleeding associated with new oral anticoagulants.
Using a systematic review approach, we aimed to identify studies describing
reversal strategies for dabigatran, rivaroxaban, and apixaban. The search was
conducted using Medline, EMBASE, HealthSTAR, and grey literature. We included
laboratory and human studies. We included 23 studies reported in 37 out of 106
potentially relevant references. Four studies were conducted in humans and the
rest were in vitro and in vivo studies. The majority of the studies evaluated the
use of prothrombinase complex concentrate (PCC), either activated or inactivated,
and recombinant activated factor VII (rFVIIa). Other interventions were also
identified. Laboratory studies suggest that hemostatic parameters and bleeding
might be partially or completely corrected by PCC for rivaroxaban better than
dabigatran. Studies in humans suggest that PCC might reverse the effects of
rivaroxaban better than dabigatran assessed by hemostatic tests. We were not able
to locate studies evaluating the clinical efficacy of these agents. The best
available evidence suggests that PCC (activated or inactivated) might be the best
option for reversing new anticoagulants. Evidence for rFVIIa is less compelling.
There might be differences in the efficacy of reversing agents for different
anticoagulants. Studies assessing the clinical efficacy of these reversal agents
are urgently needed.