title: Reversal agents for direct oral anticoagulants: A focused review.
abstract: For several decades the vitamin K antagonist oral anticoagulants were the only outpatient therapy that existed to reduce the risk of stroke and thromboembolism. When the new direct oral anticoagulants were approved for use and addressed many of the issues associated with oral vitamin K antagonists, a new concern arose-the lack of rapid ability to reverse these agents. Physicians and patients were concerned that in cases of life-threatening bleeding or need for emergent surgery, an antidote to reverse the anticoagulation effect of these agents did not exist. Contemporary research has aimed to produce reversal agents that can be administered to safely neutralize the anticoagulant effect. In this focused review we describe the clinical development as well as mechanisms of action of three agents (idarucizumab, andexanet alpha, and ciraparantag). We review the pharmacokinetics, animal and human study data of these reversal agents and outline the evidence supporting their use. Although questions of safety and appropriate use remain, these reversal agents offer a significant step forward in the widespread use of direct oral anticoagulants and overall management of the anticoagulant effect.
authors.affiliation: Cardiac Electrophysiology Section, Division of Cardiology, Department of Medicine, University of California, San Diego, La Jolla, CA 92037, United States.
authors.forename: Boris
authors.initials: B
authors.lastname: Arbit
authors.affiliation: Cardiac Electrophysiology Section, Division of Cardiology, Department of Medicine, University of California, San Diego, La Jolla, CA 92037, United States.
authors.forename: Marin
authors.initials: M
authors.lastname: Nishimura
authors.affiliation: Cardiac Electrophysiology Section, Division of Cardiology, Department of Medicine, University of California, San Diego, La Jolla, CA 92037, United States. Electronic address: Jonathan.Hsu@ucsd.edu.
authors.forename: Jonathan C
authors.initials: JC
authors.lastname: Hsu
mesh_terms: D000818:Animals; D061067:Antibodies, Monoclonal, Humanized / Q000627:therapeutic use*; D000925:Anticoagulants / Q000494:pharmacology*; D001120:Arginine / Q000031:analogs & derivatives* / Q000627:therapeutic use; D015951:Factor Xa / Q000627:therapeutic use*; D006801:Humans; D010879:Piperazines / Q000627:therapeutic use*; D011994:Recombinant Proteins / Q000627:therapeutic use*
chemical_list: D061067:Antibodies, Monoclonal, Humanized; D000925:Anticoagulants; C580915:PRT064445; D010879:Piperazines; D011994:Recombinant Proteins; D001120:Arginine; C000594745:idarucizumab; D015951:Factor Xa; C000593571:PER977
keywords: Anticoagulation; Direct oral anticoagulants; Reversal