• Daniele Orso, Federico Fonda, Alessandro Brussa, Irene Comisso, Elisabetta Auci, Marco Sartori, and Tiziana Bove.
• Azienda Sanitaria Universitaria Friuli Centrale, Department of Emergency "Santa Maria Della Misericordia", University Hospital of Udine, Piazzale Santa Maria Della Misericordia, N.15, 33100, Udine, UD, Italy. sd7782.do@gmail.com.
• Crit Care. 2024 Jul 5; 28 (1): 221221.

BackgroundThere is currently a lack of evidence for the comparative effectiveness of Andexanet alpha and four-factor prothrombin complex concentrate (4F-PCC) in anticoagulation reversal of direct oral anticoagulants (DOACs). The primary aim of our systematic review was to verify which drug is more effective in reducing short-term all-cause mortality. The secondary aim was to determine which of the two reverting strategies is less affected by thromboembolic events.MethodsA systematic review and meta-analysis was performed.ResultsTwenty-two studies were analysed in the systematic review and quantitative synthesis. In all-cause short-term mortality, Andexanet alpha showed a risk ratio (RR) of 0.71(95% CI 0.37-1.34) in RCTs and PSMs, compared to 4F-PCC (I2 = 81%). Considering the retrospective studies, the pooled RR resulted in 0.84 (95% CI 0.69-1.01) for the common effects model and 0.82 (95% CI 0.63-1.07) for the random effects model (I2 = 34.2%). Regarding the incidence of thromboembolic events, for RCTs and PSMs, the common and the random effects model exhibited a RR of 1.74 (95% CI 1.09-2.77), and 1.71 (95% CI 1.01-2.89), respectively, for Andexanet alpha compared to 4F-PCC (I2 = 0%). Considering the retrospective studies, the pooled RR resulted in 1.21 (95% CI 0.87-1.69) for the common effects model and 1.18 (95% CI 0.86-1.62) for the random effects model (I2 = 0%).ConclusionConsidering a large group of both retrospective and controlled studies, Andexanet alpha did not show a statistically significant advantage over 4F-PCC in terms of mortality. In the analysis of the controlled studies alone, Andexanet alpha is associated with an increased risk of thromboembolic events.Clinical Trial RegistrationPROSPERO: International prospective register of systematic reviews, 2024, CRD42024548768.© 2024. The Author(s).

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