TABLE 7 ] Comparison of Speci c NOAC Reversal Agents Idaracizumab Andexanet alfa Ciraparantag Company Boehringer Ingelheim Portola Pharmaceuticals Perosphere Inc. Chemical structure Humanized monoclonal antibody fragment Recombinant truncated human factor Xa variant (decoy) Synthetic water-soluble cationic small molecule consisting of 2 L-arginine units connected with a piperazine containing linker chain Binding Noncompetitive binding to dabigatran Competitive binding to direct factor Xa inhibitors or to indirect factor Xa inhibitor- activated antithrombin Covalent hydrogen bonding Target af nity Approximately 350 greater af nity for dabigatran than factor IIa Af nity for direct factor Xa inhibitors similar to that of native factor Xa Not reported Onset < 5 min 2 min 5-10 min Half-life Initial: 47 min Terminal: 10.3 h Terminal: approximately 6 h Duration of action 24 h Elimination Kidney (protein catabolism) Not reported Not reported Anticoagulant(s) reversed Dabigatran Direct and indirect factor Xa inhibitorsa - Dabigatran - Argatroban - Low-molecular-weight heparins - Unfractionated heparin - Oral and parenteral factor Xa inhibitors Route and dose in clinical studies 5 g administered as 2 doses of 2.5 g IV over 5-10 min, 15 min apart (repeat dosing can be considered if recurrent bleeding or require second emergent procedure if elevated coagulation parameters) 400-800 mg IV bolus (30 mg/min) followed by infusion of 4-8 mg/minb 100-300 mg IV bolus Storage Refrigerated Refrigerated Room temperature (Adapted from Ruff et al.204 ) a For the indirect factor Xa inhibitors, andexanet alfa likely to completely reverse fondaparinux which only inhibits factor Xa but not low-molecular weight heparins which also inhibit factor IIa. b Lower dose to reverse apixaban, higher dose to reverse rivaroxaban. Practical Issues With VKA and NOAC Cardioversion Antithrombotic Therapy for Patients With AF Undergoing Cardioversion: In AF of documented short duration (ie, # 48 h), urgent cardioversion commonly occurs without prolonged pre-cardioversion anticoagulation. 