617: Management strategies of patients receiving fxa inhibitors or LMWH admitted for ICH
Learning Objectives: Despite their clinical benefits, oral Factor Xa inhibitors (FXaI) have shown a risk of intracranial bleeding associated with high morbidity and mortality. Currently there are no approved antidotes to reverse FXaI-associated bleeding, with typical treatments including non-specific coagulation or plasma products and supportive therapies/interventions. This study evaluated real-world utilization and outcomes of FXaI-associated intracranial hemorrhage (ICH) based on management approach.
Methods: Five US medical centers participated in a retrospective study of patients admitted to the hospital with life-threatening bleeding on or after January 2014 while on apixaban, rivaroxaban, or therapeutic low molecular weight heparin. Patients were ineligible if receiving warfarin or dabigatran within 7 days of admission.
Results: Records of 56 patients with life-threatening hemorrhage on direct and indirect FXaI were assessed, 19 of which were found to have FXaI-associated ICH. Of known causes, 10(63%) were spontaneous and 6(38%) were traumatic. Of the spontaneous ICHs, 6 were intraparenchymal, 3 were hemorrhagic transformation of ischemic stroke, and 1 was an aneurysmal subarachnoid hemorrhage (SAH). Of the traumatic ICHs, there was equal distribution of subdural hemorrhage, SAH and intraparenchymal contusions. 14(74%) received coagulation factor products (8 FEIBA, 2 PCC), and 1 received plasma. The 2 patients on the indirect FXaI enoxaparin all received protamine sulfate. 5(26%) patients received only supportive care. 7(37%) patients died within 30 days, 5 of which died in the ICU. No significant differences were observed in treatment, resources, or mortality between those who received coagulation products or reversal agents and those who did not.
Conclusions: In the absence of a specific reversal agent, treatment approaches to FXaI-associated ICH remain varied, and in this small sample there were no differences in outcomes, which remain poor and similar to warfarin-associated ICH. This highlights the need for developing specific treatment strategies that can improve ICH outcomes in this patient population.
Milling TJ, Clark CL, Feronti C, Song SS, Torbati SS, Fermann GJ, et al. Management strategies of patients receiving fxa inhibitors or LMWH admitted for ICH. Society of Critical Care Medicine, Honolulu, HI, January 21-27, 2017. World Intercranial Hemorrhage Conference (WICH), Boston, MA, May 1-3, 2017.