cost comparison of andexanet versus prothrombin complex concentrates for direct factor xa inhibitor reversal after hemorrhage

Andexanet-alpha is a specific reversal agent for direct factor xa inhibitors (dfxai). we aimed to project utilization rates and cost of andexanet for reversal of dfxai-related major hemorrhage compared to 4-factor prothrombin complex concentrates (4f-pcc). a retrospective, multicenter review was conducted between 1/1/2014 and 7/15/2018 of patients who received 4f-pcc for reversal of dfxai-related life-threatening hemorrhages. total hospital reimbursements/patient were calculated based on national average ms-drg payments adjusting for medicare discounts. the projected cost for andexanet (based on dose and insurance) and % reimbursement/patient was compared to the actual cost of 4f-pcc. hemostasis at 24 h (excellent/good vs. poor) and 30-day thrombotic complications were assessed. of 126 patients who received 4f-pcc to reverse dfxai, 46 (~ 10 per-year) met inclusion criteria. the median projected cost of andexanet was $22,120/patient, compared to $5670/patient for 4f-pcc (p < 0.001). the median hospital reimbursement was $11,492/hospitalization. the projected cost of andexanet alone would exceed the entire hospital reimbursement in 74% of patients by a median of $7604, while 4f-pcc cost exceeded the total hospital payments in 7% of patients in the same cohort (p < 0.001). hemostasis was excellent/good in 72% of patients post-4f-pcc, compared to 82% in andexanet trials. thromboembolic events occurred in 4% of patients following 4f-pcc versus 10% in andexanet trials. the projected cost of andexanet would exceed the national average hospital reimbursement/patient in nearly 75% of patients by over $7500/hospitalization. 4f-pcc was significantly less expensive, had lower rates of thrombosis, but also lower rates of good/excellent hemostasis compared to published data for andexanet.