REBEL EM - November 28, 2022 -By Carlton C.L. Watson
Article: Costa O.S. et al. Andexanet alfa versus four-factor prothrombin complex concentrate for the reversal of apixaban- or rivaroxaban-associated intracranial hemorrhage: a propensity score-overlap weighted analysis. Crit Care 26, 180 (2022). PMID: 35710578
Clinical Question: Compared to 4F-PCC, is Andexanet-alfa safe and effective for the reversal of factor Xa inhibitor-associated intracranial hemorrhages?
Author’s Conclusion: “Our indirect comparison analysis of ANNEXA-4 derived Andexanet alfa patients and a synthetic control arm of 4F-PCC patients from a US healthcare system showed that Andexanet alfa was associated with better hemostatic effectiveness and reduced odds of all-cause mortality at 30 days. Our findings support current consensus guidelines, which preferentially recommend using Andexanet alfa over 4F-PCC for the management of apixaban- or rivaroxaban-associated life-threatening bleeds, including intracranial hemorrhage.”
Our Conclusion: The numerous methodologic concerns and conflicts of interest in this trial and the parent (ANNEXXA-4) trial make us wary about the data presented. Until large, externally validated, randomized controlled trials prove otherwise, we remain skeptical about the efficacy of Andeaxanet alfa for managing apixaban- or rivaroxaban-associated life-threatening bleeds, including intracranial hemorrhage.