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Nothing should strike terror in the heart of a neurologist or emergency medicine physician more than a patient with an intracranial hemorrhage while receiving novel oral anticoagulant (NOAC) therapy. The problem, of course, is that until recently, there have been no proven effective agents for emergency reversal of direct factor Xa antagonists and direct thrombin inhibitors. The current state of the art for reversing warfarin and other vitamin K antagonists is use of a 4-factor prothrombin complex concentrate.1 For the NOACs, we have had no analogous “silver bullet.” In recent trials comparing various forms of anticoagulation for atrial fibrillation, NOAC-associated intracranial hemorrhage has been associated with mortality rates of 45% to 67%.2- 4 With no evidence to guide treatment decisions, clinicians on the front lines have been forced to improvise. Fresh frozen plasma; 3-factor, 4-factor, and activated prothrombin complex concentrates PCCs; recombinant factor VIIa; and cryoprecipitate have all been tried, alone or in combination, in an attempt to do something, anything. Adding to the chaos, there have been no data systematically evaluating the potential efficacy of these treatments.
Mayer SA. Emergency Reversal of Novel Oral AnticoagulantsHelp Is on the Way. JAMA Neurol. 2016;73(2):155-156. doi:10.1001/jamaneurol.2015.3884