ESOC 2023 | Reversal agents for the management of oral anticoagulant-associated ICH

When intracerebral hemorrhage occurs in an anticoagulated patient, immediate treatment cessation and reversal is crucial given the high mortality and morbidity associated with oral anticoagulant-associated intracerebral hemorrhage (OAC-ICH). Ashkan Shoamanesh, MD, McMaster University, Hamilton, Canada, discusses the management of OAC-ICH, highlighting specific considerations for different types of OACs. For vitamin K antagonists (VKA), prothrombin complex concentrate (PCC) is used for anticoagulation reversal, alongside intravenous vitamin K administration necessary for the synthesis of clotting factors. For direct thrombin inhibitors like dabigatran, direct reversal with idarucizumab is recommended. Compared with warfarin, factor Xa inhibitors, such as apixaban, rivaroxaban, and edoxaban, reduce the risk of ICH by more than 50%. Despite this, as many as 0.5% of patients taking FXa inhibitors will still experience an intracranial bleeding event with each year of therapy. Andexanet alfa has been approved as a direct reversal agent for factor 10a inhibitors, but is often not available, in which case PCC is recommended as an alternative. This interview took place during the European Stroke Organisation Conference (ESOC) in Munich, Germany.

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