The following is the summary of “Four-factor prothrombin complex concentrate administration after expanding intracranial hemorrhage status post administration of andexanet alfa” published in the December 2022 issue of Emergency medicine by Blackburn, et al.

Current guidelines provide few suggestions for a preferred reversal medication for life-threatening bleeding related to the use of oral factor Xa inhibitors. The use of further reversal agents is not strongly encouraged when the first one does not produce the required hemostatic reaction. An apixaban (ELIQUIS)-treated 86-year-old woman with atrial fibrillation presented from another facility after experiencing an intracranial hemorrhage of spontaneous origin (sICH). The Computed tomography (CT) showed multifocal sICH on the left side. The patient was given andexanet alfa (AA) to reverse the effects of apixaban for sICH. 

Repeat CT scans taken at the receiving ED revealed an increasing sICH, more midline shift, and low-molecular-weight heparin levels of 2 IU/mL, indicating therapeutic apixaban efficacy. After that, we gave the patient a concentrate on the four factors of the prothrombin complex (4F-PCC). The following are some of the most important reasons why an emergency medicine specialist should be aware of this. When andexanet alfa (AA) does not deliver sufficient or desired hemostasis, there are no recommendations for the next therapeutic step in the current anticoagulation reversal guidelines.

Patients with life-threatening bleeding from factor Xa inhibitors who need both AA and 4-factor prothrombin complex concentrate have a small body of evidence and reported outcomes (4F-PCC). When considering the use of both medications to achieve the required hemostatic condition due to factor Xa inhibitor-associated bleeding, the risks and benefits should be examined at length.