288Thrombotic events in bleeding patients treated with andexanet alpha: an ANNEXA-4 sub-study
Authors: Beyer-Westendorf J , Yue P , Crowther M , Eikelboom J W , Gibson C M , Milling T J , Albaladejo P , Cohen A T , Demchuk A M , Lopez-Sendon J , Middeldorp S , Schmidt J , Verhamme P , Curnutte J T , Connolly S J 
Published: October 2019

Abstract

Background/Introduction
Andexanet alfa (“andexanet”) was developed as a specific reversal agent for patients with major bleeding while using factor Xa (FXa) inhibitors. While thrombotic events (TEs) have been reported in patients receiving andexanet, the scope, nature, and timing of these events have not been fully characterized.

Purpose
The ANNEXA-4 study was a prospective, single-arm, open-label clinical trial that evaluated the safety and efficacy of andexanet in patients with acute major bleeding. In this secondary analysis, the occurrence of TEs was investigated.

Methods
Patients presenting with acute major bleeding within 18 hours after their last dose of FXa inhibitor were treated with andexanet. Safety outcomes, including TEs (reviewed by an adjudication committee), were evaluated at 30 days.

Results
Among 352 patients treated with andexanet, 34 (9.7%) experienced one or more TEs (Table). Strokes and deep vein thromboses were the most frequent TE types. Compared to patients with arterial TEs, patients with venous TEs were more likely to have been originally anticoagulated for venous thromboembolism. Median time to first TE was 10.5 days (Figure); time to event was shorter for arterial TEs than for venous TEs. TEs were nonfatal for most patients. Subgroups by age, bleed type, baseline anti-fXa activity, FXa inhibitor dose, and andexanet dose were not associated with the occurrence of TEs. Of the 34 TE patients, 26 (76.4%) had TEs before restart of any (full or prophylactic) anticoagulation; all first TEs occurred in patients not receiving oral anticoagulation. No TEs occurred after resumption of oral anticoagulation (N=100).
Table 1. Thrombotic event characteristics Characteristic Result (n/N [%]) TE type   Strokes 14/352 (4.0%)   Deep vein thromboses 13/352 (3.7%)   Myocardial infarctions 7/352 (2.0%)   Pulmonary embolisms 5/352 (1.4%)   Transient ischemic attacks 1/352 (0.3%) Bleed type   Intracranial 23/227 (10.1%)   Gastrointestinal 7/90 (7.8%)   Other 4/35 (11.4%) Arterial TEs   Anticoagulated for AF 17/22 (77.3%)   Anticoagulated for VTE 6/22 (27.3%) Venous TEs   Anticoagulated for AF 11/18 (61.1%)   Anticoagulated for VTE 8/18 (44.4%)   Median time to first TE 10.5 days   Arterial 6 days   Venous 15 days Outcome   Fatal 7/34 (20.6%)   Nonfatal 27/34 (79.4%) AF = atrial fibrillation; n = number of patients with TEs; N = total number of patients for each characteristic; TE = thrombotic event; VTE = venous thromboembolism.
Figure 1. Thrombotic Events Over Time

Conclusions
In patients with FXa inhibitor-associated acute major bleeding treated with andexanet, TEs occurred a rate not unexpected given the high thrombotic risk of the population. No factors predictive of TEs were identified. Resumption of anticoagulation was associated with fewer TEs.

Acknowledgement/Funding
Study funded by Portola Pharmaceuticals, Inc.