The FDA has approved use of Kcentra (CSL Behring), a human-derived 4-factor prothrombin complex concentrate (PCC), for urgent reversal of warfarin anticoagulation in adults with acute major bleeding. It is the only 4-factor PCC available in the US.

The FDA has approved edoxaban (Savaysa – Daiichi Sankyo), a once-daily, oral, direct factor Xa inhibitor, for treatment of venous thromoboembolism (VTE) and for prevention of stroke and systemic embolism in patients with nonvalvular atrial fibrillation. It is the fourth new oral anticoagulant to be approved for VTE and nonvalvular atrial fibrillation.

Coagulation factor Xa (recombinant), inactivated-zhzo (andexanet alfa; Andexxa – Portola) has received accelerated approval from the FDA for urgent reversal of the anticoagulant effect of the direct factor Xa inhibitors apixaban (Eliquis) and rivaroxaban (Xarelto). Andexanet alfa is the second antidote for a direct oral anticoagulant to become available in the US, and the fi rst for factor Xa inhibitors. Idarucizumab (Praxbind) was approved in 2015 for reversal of the anticoagulant effect of the direct thrombin inhibitor dabigatran etexilate (Pradaxa). Andexanet alfa has not...

With the widespread adoption of the CHA₂DS₂-VASc scoring system, oral anticoagulation therapy is now recommended for all patients ≥75 years old with nonvalvular atrial fibrillation. Atrial fibrillation has, however, been associated with an increased risk of falls, and older patients starting warfarin for atrial fibrillation have a high rate of hospitalization for intracranial bleeding. Many practitioners are reluctant, therefore, to prescribe an oral anticoagulant for elderly patients who are at high risk for falls.

The injectable direct thrombin inhibitor desirudin (Iprivask – Canyon), a recombinant analog of hirudin, the leech anticoagulant protein, was approved by the FDA in 2003 for prevention of venous thromboembolism (VTE) after elective hip arthroplasty, but was only marketed recently in the US. It has been available in Europe as Revasc for about 10 years. Two other hirudin analogs are available in the US: lepirudin (Refludan) for treatment of heparin-induced thrombocytopenia (HIT) and bivalirudin (Angiomax) for use in percutaneous coronary intervention (PCI).

Major orthopedic surgery creates a prothrombotic state by causing tissue injury during the operation and requiring relative immobilization during recovery. Without thromboprophylaxis, 40-60% of patients undergoing major knee or hip surgery develop venographically detectable deep vein thrombosis (DVT) and 1 in 300 undergoing total hip replacement will have a symptomatic pulmonary embolism (PE). Thromboprophylaxis reduces the incidence of venous thromboembolism (VTE), but it also can cause bleeding. New guidelines for prevention of VTE have recently been published.

The FDA has approved betrixaban (Bevyxxa – Portola), a once-daily, oral, direct factor Xa inhibitor, for prophylaxis of venous thromboembolism (VTE) in adults hospitalized for an acute medical illness who have moderately or severely restricted mobility and other risk factors for VTE. Betrixaban is the first oral anticoagulant to be approved in the US for this indication.

View the Comparison Table: Some Oral Anticoagulants for VTE

A synthetic form of the protein apoaequorin is the active ingredient in the over-the-counter dietary supplement Prevagen (Quincy Bioscience), which is heavily marketed to improve memory.

Antiplatelet drugs are the drugs of choice for prevention and treatment of arterial thrombosis. Anticoagulants are the drugs of choice for prevention and treatment of venous thromboembolism and for prevention of cardioembolic events in patients with atrial fibrillation.