Reversal Agents: What We Have and What We Can Expect

Clinical trials in patients with atrial fibrillation have demonstrated that non-vitamin K antagonist oral anticoagulants [novel oral anticoagulants (NOACs)] are markedly safer than warfarin with respect to serious bleeding—especially intracranial hemorrhage, the most feared and devastating complication of anticoagulant therapy. Registries and large retrospective database studies have confirmed these findings. Additionally, patients who do experience bleeding while taking NOACs have similar or better outcomes than do patients on warfarin. However, despite these data, many physicians and patients have been reluctant to embrace NOAC use due to their perception that they are not able to effectively manage patients who present with bleeding, particularly without a specific reversal agent or antidote on-hand. With the approval of the first NOAC-specific reversal agent and with others in late-stage clinical development, it is helpful to review how these agents may fit in the framework of managing NOAC-related bleeding.