Disadvantages of PCCs vs FFP include a small but real pro-thrombotic risk, availability at some institutions and cost. PCCs are available by IV immediately versus delay needed with FFP, and the risk of volume overload and transfusion-related acute lung injury (TRALI) with FFP is not seen with PCCs. 11 Clotting factors are 25 times more concentrated than fresh frozen plasma (FFP) and INR reverses within minutes (15–20 minutes), while it may take FFP 6 to 24 hours. PCCs have been shown to be successful in the reversal of VKAs and are considered first line treatment in patients with major bleeding on VKAs. Four-factor (4F-) PCC may be inactive (4F-PCC K-centra, Octaplex) or active (4F-aPCC FEIBA) this is determined by the Factor VII component. Depending on the agent used, they may contain three factors (II, IX, X) or four factors (II, VII, IX, X). Prothrombin complex concentrates have been developed to contain highly concentrated coagulation factors along with antithrombotic agents. 5 Similar to stated above, a normal PT/INR does not exclude some degree of anticoagulant effect, but merely indicates a level below that expected at therapeutic dosing. 3, 5, 6 Apixaban weakly affects the PT/INR levels. At therapeutic serum concentrations, one would expect both rivaroxaban and edoxaban to cause elevation of the PT/INR. Of the direct oral Xa inhibitors, rivaroxaban has the strongest effect on the PT/INR. In a patient taking dabigatran, an elevated INR is an indication of serum levels three to four times the upper limit of normal therapeutic concentrations. 3 – 5Īt therapeutic levels of dabigatran, an abnormality of the PT/INR is not expected. The degree of elevation is specific to the reagent as well as the calibration of the laboratory equipment. Similar to aPTT, PT/INR is variably affected by the DOACs. Prothrombin time (PT) / international normalized ration (INR) is a measure of the extrinsic and common pathway it is useful to determine the anticoagulation status of patients receiving VKAs. Prothrombin Time (PT) and International Normalized Ratio (INR) See Figure 1 for an overview of the coagulation cascade and site of action of the anticoagulants. Note that each direct factor Xa inhibitor has the letters “Xa” in its spelling. The DOACs act directly upon Factors IIa (DTIs) or Xa (“Xabans”) without using antithrombin as a mediator. Examples of DOACs include the following: direct thrombin inhibitors (DTIs) dabigatran (Pradaxa) and direct factor Xa inhibitors (“Xabans”) rivaroxaban (Xarelto), apixaban (Eliquis) and edoxaban (Lixiana, Savaysa). Target-specific oral anticoagulants (TSOACs) or direct oral anticoagulants (DOACs) were developed to provide more stable pharmacokinetic and pharmacodynamic options for oral anticoagulation. VKAs reduce the synthesis of factors II, VII, IX and X thereby reducing ability to generate active thrombin, rather than inhibition of activated enzymes. Once an injectable indirect factor Xa and IIa inhibitor has been selected, an oral vitamin K antagonist (VKA), traditionally warfarin (Coumadin), is started on the same day. Finally, Fondaparinux (Arixtra) is an exclusive indirect factor Xa inhibitor. Enoxaparin (Lovenox), a low-molecular-weight-heparin (LMWH), inhibits factors Xa and to a lesser extent IIa.
UFH also inhibits factors XIIa, XIa and IXa. Examples of injectable indirect factor Xa and IIa inhibitors include unfractionated heparin (UFH), which inhibits factors Xa and to a lesser extent IIa. Medical conditions associated with antidotes:Īlways consult your healthcare provider to ensure the information displayed on this page applies to your personal circumstances.Physicians have numerous anticoagulation treatment options in their arsenal including the traditional injectable indirect factor Xa and IIa (thrombin) inhibitors, which are mediated through an antithrombin dependent mechanism.
Generic name: pentetate calcium trisodiumįor ratings, users were asked how effective they found the medicine while considering positive/adverse effects and ease of use (1 = not effective, 10 = most effective). Generic name: sodium nitrite/sodium thiosulfate Generic name: glycopyrrolate / neostigmine
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