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Meta-Analysis
. 2022 Nov 1;5(11):e2240145.
doi: 10.1001/jamanetworkopen.2022.40145.

Evaluation of Direct Oral Anticoagulant Reversal Agents in Intracranial Hemorrhage: A Systematic Review and Meta-analysis

Rahul Chaudhary  1 , Amteshwar Singh  2 , Rohit Chaudhary  3 , Michael Bashline  1 , Damon E Houghton  4   5 , Alejandro Rabinstein  6 , Jill Adamski  7 , Richard Arndt  8 , Narith N Ou  9 , Maria I Rudis  10 , Caitlin S Brown  10 , Erin D Wieruszewski  10 , Matthew Wanek  11 , Nathan J Brinkman  9 , Jane A Linderbaum  12 , Melissa A Sorenson  13 , John L Atkinson  14 , Kristine M Thompson  15 , Aryan N Aiyer  1 , Robert D McBane 2nd  4
Affiliations
Meta-Analysis

Evaluation of Direct Oral Anticoagulant Reversal Agents in Intracranial Hemorrhage: A Systematic Review and Meta-analysis

Rahul Chaudhary et al. JAMA Netw Open. .

Abstract

Importance: Direct oral anticoagulant (DOAC)-associated intracranial hemorrhage (ICH) has high morbidity and mortality. The safety and outcome data of DOAC reversal agents in ICH are limited.

Objective: To evaluate the safety and outcomes of DOAC reversal agents among patients with ICH.

Data sources: PubMed, MEDLINE, The Cochrane Library, Embase, EBSCO, Web of Science, and CINAHL databases were searched from inception through April 29, 2022.

Study selection: The eligibility criteria were (1) adult patients (age ≥18 years) with ICH receiving treatment with a DOAC, (2) reversal of DOAC, and (3) reported safety and anticoagulation reversal outcomes. All nonhuman studies and case reports, studies evaluating patients with ischemic stroke requiring anticoagulation reversal or different dosing regimens of DOAC reversal agents, and mixed study groups with DOAC and warfarin were excluded.

Data extraction and synthesis: Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines were used for abstracting data and assessing data quality and validity. Two reviewers independently selected the studies and abstracted data. Data were pooled using the random-effects model.

Main outcomes and measures: The primary outcome was proportion with anticoagulation reversed. The primary safety end points were all-cause mortality and thromboembolic events after the reversal agent.

Results: A total of 36 studies met criteria for inclusion, with a total of 1832 patients (967 receiving 4-factor prothrombin complex concentrate [4F-PCC]; 525, andexanet alfa [AA]; 340, idarucizumab). The mean age was 76 (range, 68-83) years, and 57% were men. For 4F-PCC, anticoagulation reversal was 77% (95% CI, 72%-82%; I2 = 55%); all-cause mortality, 26% (95% CI, 20%-32%; I2 = 68%), and thromboembolic events, 8% (95% CI, 5%-12%; I2 = 41%). For AA, anticoagulation reversal was 75% (95% CI, 67%-81%; I2 = 48%); all-cause mortality, 24% (95% CI, 16%-34%; I2 = 73%), and thromboembolic events, 14% (95% CI, 10%-19%; I2 = 16%). Idarucizumab for reversal of dabigatran had an anticoagulation reversal rate of 82% (95% CI, 55%-95%; I2 = 41%), all-cause mortality, 11% (95% CI, 8%-15%, I2 = 0%), and thromboembolic events, 5% (95% CI, 3%-8%; I2 = 0%). A direct retrospective comparison of 4F-PCC and AA showed no differences in anticoagulation reversal, proportional mortality, or thromboembolic events.

Conclusions and relevance: In the absence of randomized clinical comparison trials, the overall anticoagulation reversal, mortality, and thromboembolic event rates in this systematic review and meta-analysis appeared similar among available DOAC reversal agents for managing ICH. Cost, institutional formulary status, and availability may restrict reversal agent choice, particularly in small community hospitals.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Rabinstein reported serving on a clinical end point committee for Boston Scientific and serving on the advisory boards of AstraZeneca and Novo Nordisk outside the submitted work. Dr Brown reported receiving grants from Alexion/AstraZeneca outside the submitted work. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Primary Anticoagulation Reversal Outcomes for 4-Factor Prothrombin Complex Concentrate and Andexanet Alfa
Figure 2.
Figure 2.. Mortality With 4-Factor Prothrombin Complex Concentrate, Andexanet Alfa, and Idarucizumab
Figure 3.
Figure 3.. Thromboembolic Events With 4-Factor Prothrombin Complex Concentrate, Andexanet Alfa, and Idarucizumab
Figure 4.
Figure 4.. Comparison of 4-Factor Plasma Concentrate Complex (4F-PCC) vs Andexanet Alfa (AA) for Proportion of Anticoagulation Reversed, Mortality, and Thromboembolic Outcomes Among Patients Receiving Factor Xa Inhibitors With Intracranial Hemorrhage
See this image and copyright information in PMC

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