s.

What are your thoughts on how quickly xarelto and eliquis stop being effective. My understanding is that it is fast compared to warfarin. But cannot reverse in hours as is the case with warfarin. I like xarelto and eliquis for patients going in for planned surgery because we don't have to do a lot of bridging like we did with warfarin which was a pita. Do you have idarucizumb in America. Apparently it reverses dabigatran in minutes. And only costs 4000 dollars.

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They constantly try to escape from the darkness outside and within
Dreaming of systems so perfect that no one will need to be good T.S. Eliot

This is sort of interesting, and gets into some of the theoretical. Bare with me, as I may ramble.

Half-life of Xarelto is about 5-9 hours, or 11-13 hours for older patients. Eliquis is about 12 hours. So over the course of 1-2 days, the effectiveness wanes. When I do lung biopsy procedures, I have folks hold 36-48h and we good to go.

This is the issue with using 4-Factor PCC as the default reversal agent for DOACs in places that don't have Andexanet. PCC is II, VII, IX, and X, which is why it is immediately effective in reversing Warfarin when given with Vitamin K.

The DOACs are Xa inhibitors. Andexanet works to block this pathway immediately. PCC doesn't, but the idea is that it at least has Factor X, so hopefully you are overcoming the DOAC effect by providing more X. And then maybe some additional benefit of adding other clotting factors. But, there are studies that suggest it isn't really PCC that helps with hemostasis, but more the timing of bleeding event relative to last dose of medication. So if I admit an ICH, and last dose of DOAC was 18 hours before, and repeat CT in 6 hours is stable, did I get hemostasis because we gave PCC or because they were far enough out from last dose that they were able to achieve spontaneous hemostasis? Similar argument for any other routine bleeding event on DOAC, and we give PCC.

As I mentioned in my initial post, I chair our clotting and anticoagulation committee. We meet monthly, and one of our roles is to review every single anticoagulation reversal given in our system each month. Pharmacy residents prepare, and we have a database of every patient who presents on Warfarin, Xarelto, Eliquis, or Pradaxa, what their bleeding event is (GI, ICH, massive epistaxis, etc) and then what they are given. We do have idarucizumb, btw. So I am privy to all cases.

Our data shows pretty similar outcomes whether presenting on Warfarin or DOAC, when managed aggressively. It should be hard to bleed to death in a hospital, in general. Outcomes are overwhelmingly pretty good. Unless it is a complication of a terminal disease state, and then goals of care become deciding factor.

So my long-winded answer to your questions is that within two half-lives, you are likely starting to approach near normal, or at least reasonable spontaneous hemostasis. If you end up in a center that only has PCC, I think that likely has some effect and benefit in emergent setting. And in my bias, I remain cautious of Andexanet. It is a great agent when needed by surgeon for emergent intervention. But then risk of thrombosis later is real. Head to head study Andexanet vs. PCC. Andexanet is more effective but higher incidence thrombotic events.

Hey lady. Status update requested. 5 days left of non weightbearing? How are you feeling?

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maybe she's born with it, maybe it's chlorine
If you're injured and need some sympathy, PM me and I'm very happy to write back.
disclaimer: PhD not MD

Hey Dr. T - thanks for checking in.
Knee is feeling good. I’ve got great range of motion - can fully flex and extend the leg - just slowly. Doing my old school Jazzercise exercises (running joke with my 20 something PT who doesn’t know what Jazzercise is) to try to keep some strength in it because damn that leg is weak. And honestly the PE has kicked my butt. I’m back to being exhausted from doing very little, but I know that will get better soon. Thank goodness for pain killers and blood thinners!

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Harry: "I expected the Rocky Mountains to be a little rockier than this."
Loyd: "I was thinking the same thing. That John Denver's full of shit, man."

Hey you. I think you can stand on your own two feet right now. I hope you can. How are you?

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maybe she's born with it, maybe it's chlorine
If you're injured and need some sympathy, PM me and I'm very happy to write back.
disclaimer: PhD not MD