Direct Oral Anticoagulant Reversal: Idarucizumab and Andexanet

Direct oral anticoagulants (DOACs) include the direct thrombin inhibitor dabigatran and the factor Xa inhibitors apixaban, rivaroxaban and edoxaban. Specific reversal agents are now available for emergency situations: idarucizumab is a humanized monoclonal antibody fragment that binds dabigatran with very high affinity, and andexanet alfa is a recombinant modified factor Xa decoy that sequesters factor Xa inhibitors.

Indications for reversal include life-threatening or uncontrolled bleeding, intracranial hemorrhage and need for urgent surgery or invasive procedures. Decision making relies on the timing of the last DOAC dose, renal function, type of bleeding and the urgency of intervention.

Idarucizumab is administered as 5 g IV in two divided 2.5 g doses over 5-10 minutes. Andexanet alfa requires a low- or high-dose regimen based on factor Xa inhibitor type, dose and timing. Both agents are expensive, time-sensitive and require coordinated emergency department and pharmacy protocols.