The reversal effect of prothrombin complex concentrate (PCC), activated PCC and recombinant activated factor VII in apixaban‐treated patients in vitro

ESSENTIALS: An antidote for apixaban is not yet available. We tested the effect of different haemostatic agents to reverse the apixaban effect in vitro. Activated prothrombin complex concentrate (aPCC) was superior to prothrombin complex concentrate and recombinant activated factor VII. Even low doses of aPCC reversed the apixaban effect completely in vitro. BACKGROUND: The number of patients under treatment with FXa inhibitors is increasing, but there is no concensus on how to reverse their anticoagulant effect in case of a life‐threatening bleeding. A specific antidote is not yet commercially available. Prothrombin complex concentrate (PCC), activated PCC (aPCC) and recombinant factor VIIa (rFVIIa) are suggested available reversal agents. OBJECTIVES: To find the most effective reversal agent to apixaban and to determine the optimal dose. PATIENTS/METHODS: PCC, aPCC, and rFVIIa at concentrations imitating 80%, 100%, and 125% of suggested therapeutic doses were added to blood drawn from apixaban‐treated patients (n=30). aPCC was also tested in a 50% dose. Samples from healthy subjects (n=40) were used as controls. Thromboelastometry in whole blood (WB) and thrombin generation in platelet‐poor plasma (PPP) were measured to assess the reversal effect. RESULTS: aPCC shortened clotting time (CT) in WB, and increased the peak thrombin concentration and velocity index in PPP to a greater extent than PCC and rFVIIa. No significant differences were seen between rFVIIa and aPCC on thrombin generation lag time, or between PCC and aPCC on endogenous thrombin potential (ETP). The 50% dose of aPCC had a slightly inferior effect, but was comparable to the other reversal agents. CONCLUSIONS: In this in vitro study the 80% dose of aPCC (40 IU/kg) reversed the anticoagulant effect of apixaban more effectively than the corresponding dose of rFVIIa and PCC both in WB (CT) and PPP (peak, ETP).