Pharmacology Rounds: Andexanet Alfa and 4-Factor PCC

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Nurses Edition Commentary

Kathy Garvin, RN and Lisa Chavez, RN
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Shawn V. -

Lots of rural EDs don't even carry PCC, would have liked a discussion on FFP as well.

Sean N. -

Hi Shawn,

Thank you for the comment!

Fresh frozen plasma was for years used, before 4 factor prothrombin complex concentrate, as one of the methods to reverse vitamin K antagonists (eg, warfarin) with vitamin K. The benefit of FFP for this indication is FFP contains all the inactive components of the coagulation cascade in physiologic concentrations. This is potentially useful in warfarin reversal as vitamin K antagonists inhibit the production of factors II, VII, IX, and X, and thus are repleted.

Fresh frozen plasma is not recommended for the reversal of direct oral anticoagulants, including the factor Xa inhibitors. This is because direct oral anticoagulants bind to specific factors. The volume needed to have a potential beneficial effect is probably over 2 L of FFP. This is a large volume and would take a long time to thaw and infuse and has a risk of adverse effects.

Other therapies that can be considered in addition to the 4 factor prothrombin complex concentrate or andexanet alfa are tranexamic acid and desmopressin, although these would be adjunctive.

One possibility for rural hospitals is to do what we do for expensive antidotes (eg, antivenom, digoxin-specific Fab fragments) and have your pharmacy develop a mechanism to share cost (ie, each regional hospital has a few vials) with a protocol to distribute within the state when needed.

If you do not have 4 factor prothrombin complex concentrate at your institution, maybe discuss with hematology and develop a protocol for how to treat and reverse direct oral anticoagulants to have in place for how to reverse.

If reversal at your institution is not possible, transferring the patient to an institution where reversal can be done is recommended.

Thanks for what you do!

Sean

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