Direct Oral Anticoagulant Reversal Agent Not Always on Hand at Trauma Centers, Acute Care Hospitals

By Linda Carroll

May 17, 2021

(Reuters Health) - Andexanet alfa, the preferred reversal agent for widely used anticoagulants known as factor Xa inhibitors, is far less likely to be in stock at acute care hospitals and trauma centers compared to a reversal agent for less commonly used blood thinners, a new study suggests.

An analysis of data from more than 4,000 U.S. hospitals revealed that 11.7% stocked andexanet alfa, the reversal agent for Xa inhibitors. In contrast, idarucizumab, the reversal agent for a less popular blood thinner, dabigatran, was available in 59.9% of hospitals, according to the results published in JAMA Network Open.

"Studies have shown that Xa inhibitors are prescribed at a rate that is 20 times that of dabigatran," said the study's lead author Dr. Zahir Kanjee, a hospitalist at Beth Israel Deaconess Medical Center in Boston and an assistant professor of medicine at the Harvard Medical School.

Both types of direct oral anticoagulant (DOAC) are considered to be safer than the older treatment, warfarin, Dr. Kanjee said. But "even though the risk of bleeds with these medications is lower than with warfarin, people still do have bleeds."

To look at the availability of the specific reversal agents to dabigatran and Xa inhibitors in U.S. hospitals, Dr. Kanjee and his colleagues turned to the Medicare Hospital Compare database to find hospitals that provide emergency care, and to websites for the pharmaceutical companies that make the reversal agents to find out which of those hospitals carried the drugs. Searches of the manufacturer websites were conducted between March 11, 2020 and November 11, 2020.

The Medicare database yielded 5,340 hospitals, of which 4,276 met the researchers' inclusion criteria. Among those hospitals, 2,562 (59.9%) carried idarucizumab and 499 (11.7%) carried andexanet alfa. Among the 528 trauma centers, 503 (95.3%) stocked idarucizumab and 151 (28.6%) stocked andexanet alfa.

While patients with bleeds can be treated with a non-specific medication (prothrombin complex concentrates), multiple medical organizations recommend the use of the specifically targeted medications, Dr. Kanjee said.

Dr. Gordon Tomaselli wasn't surprised by the new findings, in part because andexanet alfa is much more expensive than the alternatives, and also because the medication hasn't been proven to be better than the non-specific treatment.

Andexanet alfa costs about $22,000 per patient as compared to about $6,000 for 4-factor prothrombin complex concentrate, the non-specific treatment, said Dr. Tomaselli, the Marilyn and Stanley M. Katz Dean of the Albert Einstein School of Medicine in New York City.

Moreover, there aren't any large head-to head comparisons between 4-factor prothrombin complex concentrate and andexanet alfa, Dr. Tomaselli said. That's something that should be done in the future, he added.

Currently, andexanet alfa is the second choice, behind 4-factor prothrombin complex concentrate, in the American College of Cardiology set of recommendations for reversal of Xa inhibitors, Dr. Tomaselli said.

SOURCE: JAMA Network Open, online May 14, 2021.