Thrombosis and Survival after Prothrombin Complex Concentrate Use to treat Oral Anticoagulant Associated Haemorrhage

Recent trials for treatments of direct oral anticoagulant (DOAC) related acute haemorrhage have highlighted incidences of post treatment thrombosis. Prothrombin complex concentrate (PCC) is widely used for reversal of anticoagulant associated bleeding, yet thrombotic risks following PCC administration, particularly for DOACs, remain incompletely characterised in real-world settings.

This retrospective observational study analysed thrombotic and survival outcomes in 682 patients that received PCC for OAC associated haemorrhage in the Belfast Health and Social Care Trust between 2015-2021. Patients were categorised by OAC type (warfarin, rivaroxaban, apixaban and edoxaban). Primary outcome was thrombotic event rate at 30 days, while secondary outcomes included 30- and 90day mortality and anticoagulation resumption rates.

The cohort comprised 393 warfarin patients, 55 rivaroxaban, 221 apixaban and 13 edoxaban patients. Intracranial haemorrhage predominated (47-69% across DOAC groups vs. 49% warfarin). Thrombotic event rates were significantly higher in DOAC patients (rivaroxaban 13%, apixaban 8%, overall DOAC 8.7%) compared to warfarin (5%). Thirty-day mortality rates ranged from 13-23% across oral anticoagulant groups. Anticoagulation was resumed in only 29-47% of patients.

The findings suggest that PCC may be as effective as specific antidotes for DOAC reversal. In the absence of universal access to specific reversal agents, PCC continues to serve an important role in managing life threatening anticoagulant associated haemorrhage. Systematic pathways for post reversal anticoagulation resumption should be implemented to optimise patient outcomes.