Anticoagulation should be resumed as soon as medically appropriate following andexanet alfa therapy. The high-dose regimen is 800 mg intravenously (at a target dose of 30 mg/min) followed by an infusion of 8 mg/min for up to 2 hours.The low-dose regimen is 400 mg intravenously (at a target rate of 30 mg/min) followed by an infusion of 4 mg/min for up to 2 hours.The indicated dosage of andexanet alfa depends on the FXa inhibitor, FXa inhibitor dosage, and time since last FXa inhibitor dose:.It restored thrombin generation in 100% of patients within 2-5 minutes. In clinical trials, andexanet alfa decreased anti-FXa activity by 94% and 92% in patients on apixaban and rivaroxaban, respectively.Andexanet alfa is a modified recombinant human factor Xa (FXa) decoy protein that binds and sequesters apixaban or rivaroxaban it also binds and inhibits tissue factor pathway inhibitor.It also recommends off-label use of andexanet alfa for reversal of edoxaban or betrixaban. If andexanet alfa is not available, the “2020 ACC Expert Consensus Decision Pathway on Management of Bleeding in Patients on Oral Anticoagulants” recommends administration of prothrombin complex concentrate or activated prothrombin complex.Andexanet alfa is approved for patients taking apixaban or rivaroxaban who require reversal of anticoagulation due to life-threatening or uncontrolled bleeding.Availability of these agents improves the overall safety of direct oral anticoagulants.
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