A UK-wide analysis of the use of reversal agents in 198 patients on direct oral anticoagulants prior to urgent procedures

Background: Direct oral anticoagulants (DOACs) are widely prescribed but present challenges when patients require urgent invasive procedures. While idarucizumab is licensed for preprocedural reversal of dabigatran, 4-factor prothrombin complex concentrates (4F-PCCs) are often used off-label for oral factor (F)Xa inhibitors. Objectives: We aimed to describe real-world UK use of reversal agents prior to urgent procedures. Methods: We conducted a UK-wide audit of adults receiving andexanet alfa, idarucizumab, or 4F-PCC to reverse apixaban, dabigatran, edoxaban, or rivaroxaban, before urgent procedures between October 2020 and June 2023. Data were collected by members of HaemSTAR, a UK-wide network led by hematology resident doctors. Primary outcomes were (1) receipt of reversal ≤24 hours before procedure and (2) adherence to recommended dosing. Secondary outcomes included procedural bleeding risk, 90-day mortality, and 30-day thrombosis rate. Results: Data were collected on 198 patients, with 48% undergoing high-risk procedures. Median time from reversal to procedure was 1.6 hours and 76% took place within 24 hours. 4F-PCC was used in 87%, idarucizumab in 8%, and andexanet alfa in 5%. Tranexamic acid was administered in 20%, 90-day mortality was 24%, and thromboembolic events occurred in 3%, all following 4F-PCC. Conclusion: Reversal agents are frequently used prior to urgent procedures in direct oral anticoagulant–treated patients, including for low-risk interventions. There is limited evidence to support the off-label use of 4F-PCC; the risks, benefits, and cost effectiveness are uncertain. Delays to intervention, low use of tranexamic acid, and infrequent drug-level testing highlight opportunities to improve clinical workflows and inform future trials.