Pharm
Factor Xa Inhibitor
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Factor Xa Inhibitor
, FXa Inhibitor, Direct Factor Xa Inhibitors, Betrixiban
See Also
Anticoagulant
s
Clotting Pathway
Class
Direct Factor Xa Inhibitor
Factor Xa is the first step in the
Common Clotting Cascade
Mechanism
Based on naturally occurring substances
Antistasin
Isolated in 1980s from Mexican leach extract
Tick
Anticoagulant
peptide (TAP)
Isolated from the tick Ornithodoros moubata
Preparations
Rivaroxaban
(
Xarelto
)
Anticoagulation in Venous Thromboembolism
(especially in Deep Vein
Thromboembolism
)
Anticoagulation in Atrial Fibrillation
Oral
Anticoagulant
for
Atrial Fibrillation
as a second line alternative to
Warfarin
or
Dabigatran
(
Pradaxa
)
Bridging to
Transesophageal Echocardiogram
and early cardioversion in
Atrial Fibrillation
(ideal indication)
Apixaban
(
Eliquis
)
Oral anticoagluant for
Atrial Fibrillation
(released in United States in 2013)
May be associated with less
GI Bleed
ing risk than
Rivaroxaban
or
Dabigatran
Appears more effective than
Warfarin
with less risk of bleeding
Prevents 3 more strokes per 1000 patients per year than
Warfarin
Complications are less than
Warfarin
Bleeding complications: 10 per 1000 fewer than warfain each year
Deaths: 4 per 1000 fewer than
Warfarin
each year
References
Mohammed (2012) J Cardiovasc Med 13(2):73-85 [PubMed]
Fondaparinux
(
Arixtra
)
Betrixaban (Bevyxxa)
Indicated in extended-duration VTE prophylaxis for up to 5-6 weeks following non-surgical hospitalizations
May be used in patients with multiple
VTE Risk
s (e.g. immobility, age)
Expensive ($600) for an NNT 167 to prevent 1 VTE, and NNH 90 for 1 signficant bleeding episode
Garland (2018) Ann Pharmacother +PMID: 29338293 [PubMed]
Edoxaban
(
Savaysa
)
Otamixaban
Management
Reversal
Gene
ral measures
Stop offending Xa agent
Consider
Activated Charcoal
if presenting within 2 hours of suspected
Overdose
ingestion
Bleeding unlikely due to Xa agent if Anti-Xa level <0.1 IU/ml
Dialysis
is not effective (protein bound)
No human data to suggest any non-specific reversal agent is significantly effective
For serious, life threatening bleeding (e.g. CNS
Hemorrhage
following
Head Trauma
)
See
Emergent Reversal of Anticoagulation
Andexxa
or
Andexanet alfa
(
Inactivated Recombinant Factor Xa
, to be released in 2018)
Antidote for
Eliquis
(
Apixaban
) or
Xarelto
(
Rivaroxaban
), but not other Xa agents
Binds Factor Xa Inhibitors
Limits progression of bleeding within 12 hours of dose (onset as early as 1 hour)
Expensive: $25,000 to 50,000 per patient
Risk of
Hypercoagulability
complications (CVA, VTE)
Ineffective in the 25% of patients who have low anti-Factor Xa Inhibitor
References
Deloughery and Orman in Majoewsky (2013) EM:Rap 13(9): 1
Sun (2016) Crit Dec Emerg Med 30(8): 28
Connolly (2019) N Engl J Med 380(14):1326-35 +PMID:30730782 [PubMed]
Management
Other bleeding complications
Menorrhagia
Expect
Menses
to be heavier than typical while on Factor Xa Inhibitors
However, severe
Menstrual Bleeding
on Factor Xa Inhibitors is uncommon
Patients should seek medical attention for 4 soaked pads in 4 hours or more than 10 pads in 24 hours
Consider holding Factor Xa Inhibitor for one day and then restarting at same dose
References
Orman and Klein in Herbert (2017) EM:Rap 17(7): 9-11
References
Wigle (2019) Am Fam Physician 100(7): 426-34 [PubMed]
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