NUR 01.4 - Implementing andexanet alpha in the hospital – practical experience and learning points

Background: Since 2019 andexanet alpha is approved in the EU for reversal of life-threatening or uncontrolled bleeding in patients taking apixaban or rivaroxaban. Implementing a new antidote is challenging in terms of correct treatment indication, way of administration, role of laboratory tests and multidisciplinary cooperation. Nurses play an important role in the workflow of bleeding patients and subsequently the administration of andexanet alpha.

Aims: Providing practical learning points of implementing andexanet alpha, based on a case series of patients with life-threating bleeding.

Methods: Patients treated with andexanet alpha between 01.2020-12.2023 in the Maastricht University Medical Center+ were included. Indication and dosing strategy were prospectively registered for safety evaluation and critical assessment of the local implementation strategy. Demographics, laboratory results and complications were retrospectively collected from electronic patient records.

Results: In total, 40 patients with life-threatening bleeding received andexanet alpha. Most patients (87.5%) received andexanet alpha due to a intracranial bleeding (Table 1). In 65.0% a DOAC plasma concentration was measured before administration of andexanet alpha, which was in 42.3% of these patients higher than the expected value based on dosing and timing of DOAC intake (Figure 1). In 5 patients (12.5%) a bleeding complication occurred during admission, while 6 patients (15.0%) developed a thrombotic event. Practical learning points following this case series were: 1) always consult a coagulation expert about the correct indication and dosage, 2) provide clear instructions given the urgent circumstances and lack of experience, 3) provide necessary materials with the medication, 4) consider measurement of DOAC plasma concentration before administration to guide future thrombotic management.

Conclusion(s): It is vital to know how to act in case of life-threating bleeding while using apixaban and rivaroxaban. Up-to-date protocols and proper instructions to involved healthcare professionals concerning the use of andexanet alpha are crucial.