With respect to reversal of life threatening bleeds associated with the use of oral factor Xa inhibitors, current guidelines provide few recommendations for a preferred reversal agent. When the initial reversal agent fails to achieve the desired hemostatic response, there is little to no recommendations for the use of additional reversal agents.

An 86-year-old female on apixaban (ELIQUIS) for atrial fibrillation, presented from an outside hospital due to a spontaneous intracranial hemorrhage (sICH). Computed tomography (CT) scan revealed multifocal left sided sICH. Due to use of apixaban in the setting to sICH, patient received andexanet alfa (AA) for reversal. Patient was then transferred and upon arrival to receiving emergency department (ED), repeat CT scans showed an expanding sICH, progression of midline shift, and low-molecular weight heparin levels that were ≥ 2 international units (IU) per milliliter (mL), indicating therapeutic apixaban activity. The patient was subsequently given four-factor prothrombin complex concentrate (4F-PCC).