617: Management strategies of patients receiving fxa inhibitors or LMWH admitted for ICH

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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.


Society of Critical Care Medicine, Honolulu, HI, January 21-27, 2017. World Intercranial Hemorrhage conference_restricted (WICH), Boston, MA, May 1-3, 2017.