DOAC Reversal — RACP Adult Medicine MCQ

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HardEmergency MedicineDOAC ReversalRACP Adult Medicine

A 72-year-old man on rivaroxaban for AF develops a life-threatening gastrointestinal haemorrhage with a haemoglobin of 52 g/L. His last dose of rivaroxaban was 4 hours ago. What is the most appropriate reversal strategy?

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Reveal the answer and explanation

Correct answer: E — Andexanet alfa

Andexanet alfa is the specific reversal agent for rivaroxaban and apixaban (factor Xa inhibitors). It acts as a decoy receptor for factor Xa inhibitors. If andexanet alfa is unavailable, 4-factor PCC (Prothrombinex-VF + factor VII concentrate, or Octaplex) at 50 IU/kg is the recommended alternative. Idarucizumab is specific to dabigatran only. FFP is ineffective for DOAC reversal. Standard resuscitation measures (blood products, endoscopy) should proceed concurrently.

Reference: eTG – 2025 – Haematology; AMH – 2025 – DOAC Reversal Agents