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

Key Points

Question

What outcomes are associated with direct oral anticoagulant (DOAC) reversal agents in intracranial hemorrhage (ICH)?

Findings

In a meta-analysis of 32 studies including 1832 patients with ICH, 4-factor prothrombin complex concentrate (4F-PCC), andexanet alfa (AA), and idarucizumab were associated with a successful anticoagulation reversal in 77%, 75%, and 82% of patients, respectively; all-cause mortality rates were 26%, 24%, and 11%, respectively; and thromboembolic event rates were 8%, 14%, and 5%, respectively. A direct retrospective comparison of 4F-PCC with AA showed no differences in successful anticoagulation reversal, all-cause mortality, or thromboembolic events.

Meaning

In this study, factor Xa inhibitor reversal agents for ICH had similar safety profiles and outcomes, but the lack of head-to-head comparison warrants cautious interpretation.

Abstract

This systematic review and meta-analysis evaluates the safety and outcomes of direct oral anticoagulation (DOAC) reversal agents among patients with intracranial hemorrhage (ICH).

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%; I ² = 55%); all-cause mortality, 26% (95% CI, 20%-32%; I ² = 68%), and thromboembolic events, 8% (95% CI, 5%-12%; I ² = 41%). For AA, anticoagulation reversal was 75% (95% CI, 67%-81%; I ² = 48%); all-cause mortality, 24% (95% CI, 16%-34%; I ² = 73%), and thromboembolic events, 14% (95% CI, 10%-19%; I ² = 16%). Idarucizumab for reversal of dabigatran had an anticoagulation reversal rate of 82% (95% CI, 55%-95%; I ² = 41%), all-cause mortality, 11% (95% CI, 8%-15%, I ² = 0%), and thromboembolic events, 5% (95% CI, 3%-8%; I ² = 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.