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Antidotes for direct oral anticoagulants


Several years after the introduction of the direct oral anticoagulants (DOACs), two specific antidotes were authorised. Idarucizumab reverses the action of the direct thrombin inhibitor dabigatran, and andexanet alfa reduces the action of the factor Xa inhibitors rivaroxaban and apixaban. There has been limited research into the efficacy and adverse effects of these agents. Studies show that the antidotes rapidly and almost completely reverse the action of the DOACs. There has also been limited research into prothrombin complex concentrate (PCC), which was the drug of first choice before the specific antidotes had been authorised and is still the preferred drug for certain indications. There have been no studies comparing PCC with the antidotes.

  • The efficacy of idarucizumab and andexanet alfa has not been investigated in randomised studies.
  • Pre-authorisation studies show that both antidotes rapidly and almost completely reverse the effect of DOACs on the coagulation parameters. 
  • Only idarucizumab has been studied and authorised for use in emergency interventions.
  • Since studies directly comparing the two antidotes with PCC are lacking, it is not possible to make a well-founded choice for the treatment of life-threatening or uncontrolled bleeding or for reversing the action of the DOACs in emergency interventions.
  • The high cost of andexanet alfa plays a role in the decision whether or not to apply this treatment.

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Authors

  • Nienke van Rein
  • Mettine H.A. Bos