When Is Anticoagulation Reversal the Right Choice?

When the patient is bleeding and the physician is calling for immediate anticoagulation reversal, clinical expertise isn't the only critical skill the pharmacist can contribute to the care team to ensure the best outcome for the patient.

“One of the most important things that you can do is stay calm,” said Lena K. Tran, clinical pharmacist specialist at AdventHealth Kissimmee in Florida. “If you stay calm, your team stays calm. And if you panic, your team panics.”

Tran and Dareen M. Kanaan, clinical pharmacy specialist at Brigham and Women's Hospital in Boston, Massachusetts, mixed clinical and practical words of wisdom during their Dec. 11 session, To Reverse or Not to Reverse: Clinical Considerations and Strategies for Anticoagulation Reversal, at the 2024 ASHP Midyear Clinical Meeting & Exhibition in New Orleans, Louisiana.

Tran described a real-life case she was involved in when an emergency department physician was ready to order four-factor prothrombin complex concentrate (4F-PCC) to reverse apixaban in a 38-year-old woman who was coughing up blood and had blood pooling in her trachea. The patient had history of pulmonary embolism, with the most recent instance two weeks ago; she was on active cancer chemotherapy, and her hemoglobin concentration of 8.3 g/dL at admission.

Taking her own advice to not panic, Tran saw that the patient, who had been admitted 40 minutes previously, was hemodynamically stable. Tran pulled up the patient’s lengthy home medication list, which showed multiple anticoagulants, including enoxaparin.

Tran took steps to conclusively verify the enoxaparin use.

“The way I confirmed the patient was on enoxaparin was by asking the patient,” Tran said to laughter from the audience. The clinical team soon administered an appropriate dose of protamine sulfate to reverse the enoxaparin instead of giving 4F-PCC, which would not have been safe for the patient.

“My takeaway from this case is really that scrutiny does save lives,” Tran said.

Session co-presenter Kanaan emphasized that the goal and objective of anticoagulation-reversal decisions “is to be both fast and accurate.” Her portion of the presentation included a review of protamine for heparin product reversal, including dosage considerations for a complex patient case. She also reviewed the use of idarucizumab, andexanet alfa, 4F-PCC, and activated prothrombin complex concentrate as reversal agents.

Kanaan emphasized that it’s important to work quickly when considering whether to administer a reversal agent in a patient. And although laboratory test results are important when evaluating the patient, it’s essential to make a rapid decision if the bleeding is life-threatening.

“You don’t want to delay administration of any reversal while you’re awaiting labs,” she said.

Tran noted that operational considerations, such as whether reversal agents are stored in the central pharmacy, can make a difference to patient care when time is short. She encouraged the audience members to assess their organizations’ operational factors to see if changes can be made to improve the time to treatment.

“Ask yourself if 15 or 20 minutes is something that can make a big difference in your patients’ lives,” Tran said.

And while using a reversal agent may seem the like the right choice in the heat of the moment, Tran said it’s important to consider other factors, such as whether the bleeding is life-threatening and whether reversal will improve the patient’s chance for survival and is in line with the goals of care.

“Sometimes supportive care and close hemodynamic monitoring is the way to go,” Tran said. “Reversal should always be limited to situations where the immediate need for anticoagulant reversal outweighs the risk of thrombosis for the patient.”