Efficacy of pro-haemostatic agents in the management of factor Xa inhibitor-associated intracranial haemorrhages.

Background: An increasing number of patients in Australia are taking direct oral anticoagulants for a variety of indications since their introduction in the treatment landscape. There has always been some concern about the optimal management approach in the setting of major and/or life-threatening bleeding. In particular, patients who present with factor Xa inhibitor-associated intracranial haemorrhages are associated with high morbidity and mortality.

Aim: To determine the efficacy of pro-haemostatic agents in the management of factor Xa inhibitor-related intracranial haemorrhages.

Methods: A retrospective audit of rivaroxaban and apixaban-associated intracranial haemorrhages was performed between January 2015 and December 2021, inclusive.

Results: The bleeding-related mortality was similar between the patients who received pro-haemostatic agents versus patients who did not receive pro-haemostatic agents (90% vs 93% respectively). The mean volume expansion for those who received pro-haemostatic agents was +1.0mL versus -6.8 mL for patients who did not receive pro-haemostatic agents (P = 0.51, 95% confidence interval: -11.7 to +5.9).

Conclusion: Patients who presented with intracranial haemorrhages in the presence of clinically significant direct oral anticoagulant levels had a higher risk of mortality that does not appear to change with the use of prohaemostatic agents. The efficacy of prohaemostatic agents may not be as clinically significant based on real-world experience in contrast to previously reported studies.