Andexanet Withdrawn: Reappraising Anticoagulation Reversal Strategies

This NEJM state-of-the-art review reframes reversal decision-making for cardiology and anticoagulation pharmacists in light of andexanet alfa's U.S. market withdrawal and persistent thrombotic-versus-hemostatic tradeoffs across all antidote classes.

andexanet alfaidarucizumabfour-factor prothrombin complex concentrateprotamine sulfatevitamin Kdabigatranapixabanrivaroxabanedoxabandirect oral anticoagulantsvitamin K antagonistsunfractionated heparinanticoagulation reversalintracranial hemorrhagemajor bleedingreview articlethrombosis Cardiology / Anticoagulation

Background Information

Anticoagulant reversal needs evidence-driven strategies for bleeding management.

The increase in anticoagulant use has led to more bleeding events requiring reversal, necessitating effective strategies. Protamine sulfate neutralizes unfractionated heparin; four-factor prothrombin complex concentrates reverse vitamin K antagonists. Uncertainties exist regarding andexanet alfa for direct oral factor Xa inhibitors, with off-label use of prothrombin complex concentrates needing more evidence. High-quality evidence is vital for advancing anticoagulant reversal care.

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Authors: Rocca B, Ten Cate H

Citation: Rocca B, Ten Cate H Antidotes for Anticoagulation Reversal. The New England journal of medicine. 2026;394(22):2235-2254. doi:10.1056/NEJMra2506021

Article Links: PubMed · Journal / DOI

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