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Classes of Drugs and Blood Products for Acute Reversal of Anticoagulant Effect

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Anticoagulation and Hemostasis in Neurosurgery

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Abstract

The reversal of anticoagulation in a timely and safe manner is crucial to the effective management of an anticoagulated patient in need of urgent neurosurgical intervention or with evidence of bleeding affecting the central nervous system. The ongoing influx of novel anticoagulant agents into everyday clinical practice has led to unprecedented levels of complexity in the field and ever-increasing challenges for those tasked with anticoagulant reversal as a means of preserving life and function. It is imperative that the practicing neurosurgeon maintain a framework of the classes of drugs and blood products available for this purpose. The aim of this chapter is to provide such a framework, which should serve to facilitate clinical decision-making and the evaluation of emerging evidence in the field. At present, the available drugs and blood products for acute reversal of the anticoagulant effect include vitamin K, plasma and prothrombin complex concentrates, recombinant factor VIIa, and protamine sulfate. Each of these reversal options is reviewed in a structured manner that encompasses mechanism of action, onset and duration of action, means of administration, potential adverse effects, and the evidence for efficacy in treating specific anticoagulants. Furthermore, we describe emerging agents such as Andexanet alpha (PRT064445), Aripazine (PER977), and Idarucizumab, which are in various stages of clinical study for reversal of the more recent Target-Specific Oral Anticoagulants. This chapter should serve to highlight key features and considerations in a structured framework that will facilitate communication with other specialists and appraisal of forthcoming evidence in this ever-changing landscape.

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Abbreviations

VKAs:

Vitamin K antagonists

INR:

International normalized ratio

PCC:

Prothrombin complex concentrates

aPCC:

Activated prothrombin complex concentrate

FFP:

Fresh frozen plasma

ICH:

Intracerebral hemorrhage

uFH:

Unfractionated heparin

LMWH:

Low molecular weight heparin

aPTT:

Activated partial thromboplastin time

TT:

Thrombin time

CEA:

Carotid endarterectomy

TSOACs:

Target-specific oral anticoagulants

rFVIIa:

Recombinant activated factor VII

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Authors and Affiliations

  1. Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada

    Christopher D. Witiw M.D. & Michael G. Fehlings M.D., Ph.D.

  2. Faculty of Medicine, University of Toronto, Toronto, ON, Canada

    Laureen D. Hachem

  3. Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada

    Michael G. Fehlings M.D., Ph.D.

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  1. Christopher D. Witiw M.D.
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Correspondence to Michael G. Fehlings M.D., Ph.D. .

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  1. Stritch School of Medicine, Loyola University, Maywood, Illinois, USA

    Christopher M. Loftus

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Witiw, C.D., Hachem, L.D., Fehlings, M.G. (2016). Classes of Drugs and Blood Products for Acute Reversal of Anticoagulant Effect. In: Loftus, C. (eds) Anticoagulation and Hemostasis in Neurosurgery. Springer, Cham. https://doi.org/10.1007/978-3-319-27327-3_17

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