A Randomized Study of Andexanet Alfa Compared to Usual Care in Patients Receiving a Factor Xa Inhibitor Who Require Urgent Surgery or Procedure (ANNEXA-RS)

The study will aim to find out if the drug andexanet alfa is safe and effective in preventing major bleeding during urgent surgery or invasive procedures. The study will compare the use of andexanet alfa to the usual care given at the study center.

Start Date02 Aug 2024

Sponsor / Collaborator

AstraZeneca PLC

NCT05898412

/ RecruitingNot Applicable

Retrospective Real World Evidence Study to Describe Characteristics and Outcomes in Dutch Patients Admitted to the Hospital With a Factor Xa Inhibitor-associated Bleeding Treated With Andexanet Alfa

This is an observational retrospective database study of hospitalized patients treated with andexanet alfa in approximately 10 Dutch hospitals. Currently there is limited information on the patient characteristics and outcomes of patients who are treated with andexanet alfa in The Netherlands and how it is used. This is of interest for treating clinicians because there is a need for a patient profile, also due to the on par position of andexanet alfa with PCC in the Dutch national guideline.
Analysis of the data showed that 14 patients of the 218 patients included in the study (6.4%) experienced a thrombotic event (TE) within 30 days after treatment with andexanet alfa. The protocol was amended to allow for an in depth analysis of the 14 TE cases.

Start Date06 Oct 2023

Sponsor / Collaborator

AstraZeneca PLC

NCT05548777

/ CompletedNot Applicable

Andexanet Alfa and 4F-PCC Use in Patients Hospitalised With an Anticoagulant-related Major Bleed

This is an observational study based on data collected via an audit of electronic medical charts. The study population will include adult US patients treated with andexanet alfa or 4F-PCC during a hospitalization for an anticoagulation-related major bleed, and their characteristics, treatments and outcomes will be described.

Start Date15 Sep 2022

Sponsor / Collaborator

AstraZeneca PLC

100 Clinical Results associated with Andexanet alfa

100 Translational Medicine associated with Andexanet alfa

100 Patents (Medical) associated with Andexanet alfa

439

Literatures (Medical) associated with Andexanet alfa

01 Dec 2025·JOURNAL OF CRITICAL CARE

Major publications in the critical care pharmacotherapy literature: 2024

Review

Author: Brown, Sophia ; Li, Ji ; Murray, Brian ; Farrar, Julie ; Roginski, Matthew A ; Bernardoni, Brittney ; Filiberto, Dina M ; Thompson, Tori R ; Perrodin, Jenna S ; Kopp, Brian J ; Esteves, Alyson M ; Madorsky, Melanie ; Tallon, Joanna K ; Moore, Megan J

OBJECTIVES:

To summarize, analyze, and provide clinical insights on the most impactful publications related to critical care pharmacotherapy in 2024.

METHODS:

A systematic search of PubMed/Medical Literature Analysis and Retrieval System Online (MEDLINE) was conducted between January 1, 2024, and December 31, 2024. Randomized controlled trials, prospective study designs, or retrospective study designs with high-quality methodology of adult critically ill patients assessing a pharmacotherapeutic intervention and reporting clinical endpoints were considered for inclusion. An a priori defined three-round modified Delphi process was performed to achieve consensus from a multi-disciplinary and geographically diverse group of critical care clinicians, focusing on the publications deemed most impactful based on their overall contribution to scientific knowledge and novelty.

RESULTS:

The systematic search yielded a total of 1533 articles, of which 1492 were excluded. Forty-one articles were included in the modified Delphi process. In each round, articles were independently scored based on their overall contribution to scientific knowledge and novelty and articles achieving a score at or above the median proceeded to the next round of voting. The six included articles are summarized and their impact is discussed. Article topics included cessation of proton pump inhibitors during transitions of care, stress ulcer prophylaxis in mechanically ventilated patients, continuous infusion beta-lactams in sepsis, ceftriaxone for prevention of ventilator-associated pneumonia, optimal antibiotic duration for bloodstream infections, and andexanet alfa for management of intracranial hemorrhage associated with factor Xa inhibitors.

CONCLUSIONS:

This review identified, summarized, and evaluated high impact studies relevant to critical care pharmacotherapy published in 2024.

01 Nov 2025·AMERICAN JOURNAL OF EMERGENCY MEDICINE

Andexanet alfa increases 30-day thrombotic events relative to four-factor prothrombin complex concentrate for factor Xa inhibitors-related intracerebral hemorrhage in veterans

Article

Author: Han, Jin H ; Rech, Megan A ; Budde, Emily ; Huo, Zhiping ; Finch, Dezon ; Xia, Yinglin ; Evans, Charlesnika T

BACKGROUND AND OBJECTIVES:

Two hemostatic agents are commonly used to reverse factor Xa (fXa) inhibitor-related intracranial hemorrhage (ICH): andexanet alfa (AA) or 4-factor prothrombin complex concentrate (4F-PCC). We sought evaluate real-world data in Veterans diagnosed with fXa inhibitor-related ICH by comparing short-term mortality and thrombotic events in patients who received AA vs. 4F-PCC.

METHODS:

This was a national retrospective cohort from the Veteran Health Administration of AA or 4 F-PCC between January 2018 to January 2024.The primary effectiveness endpoint was 90-day mortality. The primary safety endpoint was 30-day thrombotic events (venous thromboembolism, pulmonary embolism, acute ischemic stroke [AIS], myocardial infarction), validated through manual chart review. Propensity score-matched data set was first created to balance AA and 4F-PCC by the significant demographic and clinical variables and then was used to analyze and compare the results using the complete data set.

RESULTS:

Of 19,015 Veterans with ICH, 664 Veterans received AA (n = 151) or 4F-PCC (n = 513) and 350 Veterans received a fXa inhibitor (AA n = 129; 4F-PCC n = 221). 123 matched subjects were included in the propensity-matched cohort. The AA group was more likely to be on apixaban (AA group 87.8 % vs. 4F-PCC group 77.2 %, p = 0.03). There was no difference in 90-day mortality between groups (30.9 % vs. 36.6 %, p = 0.35). The AA group experienced significantly more 30-day thrombotic events compared to 4F-PCC (11.4 % vs. 2.4 %, p < 0.01) and AIS was significantly more common with AA.

CONCLUSION:

In Veterans with fXa inhibitor-related ICH receiving AA or 4F-PCC, there was no difference in 90-day mortality. Consistent with previous literature from non-Veterans studies, 30-day thrombotic events were significantly higher in Veterans who received AA, including a significant increase in AIS. This study adds to the growing body of literature demonstrating higher thrombotic risks with AA. Selection of AA should be carefully weighed against the risk of thrombotic events.

01 Oct 2025·CLINICAL NEUROLOGY AND NEUROSURGERY

Efficacy of andexanet alfa in non-surgical patients with spontaneous DOAC related intracerebral hemorrhage

Article

Author: Sethuraman, Asha ; Grik, Evgeniia ; Reddy, Deven ; Ardelt, Agnieszka ; Bajdas, Haley ; Bowles, Alfred ; Doppelheuer, Brandon ; Roach, Mary Joan ; Hunter, Kyle ; Frantz, Tyler ; Finocchiaro, Roman ; Mezinger, Ryan ; Kelly, Michael L

INTRODUCTION:

In 2018, andexanet alfa (Andexxa) became FDA approved as an anti-factor Xa inhibitor reversal agent for patients who require the reversal of anticoagulation due to rivaroxaban (Xarelto) or apixaban (Eliquis). A key consideration when utilizing Andexxa is its notably high cost. This study's objective is to assess the clinical benefit of Andexxa on patients with spontaneous intracerebral hemorrhages (ICH) who did not undergo neurosurgical intervention.

METHODS:

For this retrospective study, the American Heart Association stroke registry was queried for patients admitted to MetroHealth for ICH between 2020 and 2023. The medical record was accessed to obtain more specific information for patients. Analyses were done to assess differences between groups.

RESULTS:

45 nonsurgical patients on a DOAC with spontaneous ICH between 2020 and 2023 were identified. There were no significant differences in baseline demographics. There were no significant differences in the baseline ICH score or the NIHSS. The Andexxa group trended towards a higher initial ICH volume (19 cc vs 7 cc; p = 0.16). We observed no significant differences in the hospital length of stay, ICH expansion volume between the two groups (2.4 cc vs 0.21 cc; p = .26) or mortality rates. Total pharmacy charges for Andexxa during the study period were $464,640.00.

CONCLUSION:

In our study, patients who received Andexxa therapy and non-surgical management of spontaneous ICH showed no difference in ICH expansion within 24 h but had increased cost of care. Further studies should examine whether Andexxa is of clinical value for patients with spontaneous ICH.

News (Medical) associated with Andexanet alfa

31 Dec 2024

·www.echemi.com

7 New Drugs Expected to Be Approved in 2025

In 2024, China approved several new drugs, and more blockbuster drugs are expected to be launched in 2025, covering oncology, autoimmune diseases, rare diseases, and other therapeutic areas. Drug Name Mechanism of Action Indications Development Institutions Evantuzumab c-Met/EGFR bispecific antibody Non-small cell lung cancer Johnson & Johnson; Genmab Taqetuzumab CD3/GPRC5D bispecific antibody Multiple myeloma Johnson & Johnson; Genmab Zenidatuzumab Anti-HER2 bispecific antibody Biliary tract cancer Zymeworks; Jazz Pharmaceuticals; BeiGene Inalises PI3Kα inhibitor HR-positive breast cancer Roche; Chugai Pharmaceutical Asunitinib STAMP allosteric inhibitor Speculated use for chronic myeloid leukemia treatment Novartis Tazemetostat EZH2 inhibitor Follicular lymphoma Epizyme; Huadong Medicine; Eisai Relatuzumab-alpha PDL1/TGF-β bispecific antibody Stomach cancer; gastroesophageal junction cancer Hengrui Medicine; Dong-A Pharma Vabysmo EGFR antibody-drug conjugate Nasopharyngeal cancer Lepu Biopharma Tenapanor NHE3 inhibitor Chronic kidney disease hyperphosphatemia Ardelyx; Kyowa Kirin; Fosun Pharma; AstraZeneca Mersutide OXM analog; GLP-1R/GCGR agonist Obesity Eli Lilly; Innovent Biologics Vusirumab IL-1β monoclonal antibody Gouty arthritis Junshi Biosciences Romosozumab SOST monoclonal antibody Osteoporosis Astellas; Amgen; UCB Teplizumab CD3 monoclonal antibody Type 1 diabetes Ligand Pharmaceuticals; Johnson & Johnson; Sanofi Solrepinib Syk inhibitor Immune thrombocytopenic purpura Huadong Medicine BBM-H901 Factor IX gene therapy Hemophilia B Gene Therapy Fitusiran RNAi therapy Hemophilia A; Hemophilia B Sanofi; Alnylam Andexanet alfa Recombinant factor Xa Factor Xa inhibitor antidote Portola Pharmaceuticals Lisocabtagene maraleucel IL-23p19 monoclonal antibody Crohn's disease Boehringer Ingelheim; AbbVie Lemborexant & Daridorexant OX1R antagonist; OX2R antagonist Insomnia Eisai & Idorsia; Sihuan Pharmaceutical; Nxera Pharma Highlights of new drug approvals in 2024 include: 1. Oncology: The world’s first antibody-drug conjugate (ADC) targeting folate receptor alpha (FRα) for ovarian cancer: Mirvetuximab soravtansine. PD-1/VEGF bispecific antibody envafolimab and Nectin-4 ADC enfortumab vedotin. 2. Autoimmune diseases: IL-17A/F monoclonal antibody bimekizumab for ankylosing spondylitis. 3. Rare diseases: Novartis’ complement factor B inhibitor for paroxysmal nocturnal hemoglobinuria (PNH). Blockbuster drugs expected to be approved in 2025 include: Oncology: Amivantamab (Q1) The world’s first c-Met/EGFR bispecific antibody. Highlight: Phase III study showed significant extension of median progression-free survival (mPFS). Talquetamab (Q2) A CD3/GPRC5D bispecific antibody and the world’s first drug targeting GPRC5D. Clinical results: Objective response rate (ORR) in Chinese patients was 69.0%-73.6%. Zanidatamab (Q2) A HER2-targeting bispecific antibody based on Azymetric™ technology. Indication: HER2-positive biliary tract cancer (BTC) with an ORR of up to 52%. Inavolisib (Q3) Roche’s highly selective PI3Kα inhibitor for PIK3CA-mutated breast cancer. Asciminib (Q3) Novartis’ Bcr-Abl allosteric inhibitor for Philadelphia chromosome-positive chronic myeloid leukemia (CML). SHR-1701 (Q4) A PD-L1/TGF-βRII bifunctional fusion protein for first-line treatment of gastric cancer. Phase III study demonstrated significant extension in median overall survival. MRG003 (Q4) China’s first EGFR-targeting ADC with remarkable efficacy in nasopharyngeal carcinoma. Endocrinology and Metabolism: Tenapanor (Q1) The world’s only approved NHE3 inhibitor for controlling hyperphosphatemia in chronic kidney disease patients. Trend Analysis: Continued Innovation in Oncology: The emergence of multiple bispecific antibodies and ADC drugs is making targets and treatment options more precise and diverse. Breakthroughs in Autoimmune and Rare Diseases: New biologics are gradually addressing drug resistance and limited treatment options in previous therapies. Emergence of Domestic Innovative Drugs: Examples include SHR-1701 and MRG003, highlighting the growing research and development capabilities of Chinese pharmaceutical companies. The sequential launch of these drugs will provide new therapeutic options for Chinese patients and enhance China’s position in the global pharmaceutical market.

Drug ApprovalPhase 3Clinical ResultADCImmunotherapy

20 Dec 2024

·www.echemi.com

AstraZeneca's Andexxa Denied Full FDA Approval

Recently, AstraZeneca announced that the FDA has rejected its application for full approval of the drug Andexxa. Andexxa was submitted for market approval in China in December 2022. Initially, it received accelerated approval from the FDA in 2018 and conditional approval from the European Union in 2019. It is primarily used to treat acute bleeding caused by apixaban and rivaroxaban and is the only drug that can specifically reverse the activity of FXa inhibitors, hence being referred to as a "life-saving drug." In 2021, AstraZeneca acquired Alexion for $39 billion, which made Andexxa part of its product line. Reports indicate that Andexxa generated sales of $182 million in 2022, marking a 23% year-on-year increase. The FDA's reason for rejection was that the data provided by AstraZeneca revealed a "significant safety issue": the thrombosis-related mortality rate among patients using Andexxa was twice that of standard treatment. AstraZeneca stated that Andexxa will remain on the U.S. market and plans to collect further data to address the FDA's concerns. If subsequent data is unfavorable, there is a risk of withdrawal from the market. This decision could affect Andexxa's fate in other markets. Currently, its application for market approval in China is still pending, and in March next year, Andexxa's conditional approval in the EU may face stricter scrutiny. "Savage" Drug Reversal Agent With the rapid growth of Xa factor inhibitors such as rivaroxaban and apixaban in thrombotic treatment, these drugs have quickly replaced warfarin as the mainstream anticoagulants. In 2019, the combined sales of rivaroxaban and apixaban reached $16.4 billion, but complaints about bleeding events have also increased. As an antidote to reverse the anticoagulant effects of "saban" drugs, Andexxa can quickly reverse their impact. In 2020, Alexion acquired Andexxa for $1.4 billion, and it subsequently fell under AstraZeneca's umbrella. AstraZeneca has high hopes for Andexxa, with sales continuing to grow, reaching $182 million globally in 2023, a 24% year-on-year increase in the first three quarters. The company is advancing post-marketing clinical trials to seek comprehensive approval. Continuing to Seek Full Approval Industry insiders were surprised by the FDA's rejection. The ANNEXA-I trial conducted in June 2023 showed that Andexxa performed well in hemostatic capability, leading AstraZeneca to terminate the clinical trial early. However, the FDA advisory committee pointed out that the incidence of thrombosis significantly increased among patients using Andexxa. Nevertheless, the FDA's stance was not entirely resolute; committee members suggested modifying the indications and dosage to better assess Andexxa's safety. Currently, AstraZeneca plans to present complete efficacy and safety data at the upcoming medical conference. If supplemental data supports its safety, Andexxa's future remains promising.

Drug ApprovalAcquisitionClinical StudyAccelerated Approval

17 Dec 2024

·www.fiercepharma.com

FDA rejects J&J's subcutaneous Rybrevant filing and AZ's full approval bid for Andexxa

The FDA has sent complete response letters to Johnson & Johnson, rejecting its subcutaneous version of Rybrevant, and to AstraZeneca, giving a thumbs down to its bid for full approval of Andexxa. Johnson & Johnson has received coal in its stocking from the FDA as manufacturing issues have tripped up the company’s attempt to gain approval of its subcutaneous version of lung cancer drug Rybrevant (amivantamab).The U.S. regulator sent J&J a complete response letter (CRL) rejecting its application to clear Rybrevant’s injected formulation for patients with non-small cell lung cancer (NSCLC) with epidermal growth factor receptor (EGFR) mutations.The FDA also has sent a CRL to AstraZeneca, swatting its request for full approval of Andexxa, which reverses the anticoagulant effect of blood thinners. The thumbs down was not a surprise as it came three weeks after an FDA advisory panel questioned Andexxa’s safety profile.The rejection for J&J was based on observations FDA officials made at a manufacturing facility during a standard pre-approval inspection. The CRL is not related to the formulation of the treatment or its efficacy or safety, the company explained in a release. The agency has not asked J&J to conduct an additional clinical study and its current approval for Rybrevant’s intravenous remains unaffected, the drugmaker added.“We’re working closely with the FDA to bring SC amivantamab to patients as quickly as possible, and are confident in our path to resolution,” Yusri Elsayed, M.D., Ph.D., J&J’s global therapeutic area head for oncology, said in a release. There has been much anticipation for Rybrevant’s injected version since the company reported seven months ago that it had performed better than intravenous Rybrevant in a clinical trial, reducing the risk of death by 38%.In August, the FDA approved Rybrevant and Lazcluse as a first-line treatment for NSCLC with EFGR mutations. A win for SC Rybrevant could help J&J in its challenge against AZ’s EGFR standout Tagrisso, which is an oral drug. While IV Rybrevant can take up to five hours to administer, the SC version only takes up to seven minutes or five minutes at median. As for the FDA's rejection of Andexxa, the company said in an email that it will keep the treatment on the market in the U.S. AZ confirmed the CRL, which was reported last week by Pink Sheet.In the first nine months of this year, Andexxa generated U.S. sales of $61 million and $159 million worldwide, which was up 24% year over year. It has been on the market since 2018 when Portola Pharmaceuticals scored its accelerated approval.In 2020, Alexion bought out Portola in a much-criticized $1.4 billion deal. A year later, AZ acquired Alexion.

Drug ApprovalAcquisitionAccelerated Approval

100 Deals associated with Andexanet alfa

External Link

KEGG	Wiki	ATC	Drug Bank
D11029	Andexanet alfa	V03AB38	DB14562

R&D Status

Approved

10 top approved records.

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Indication	Country/Location	Organization	Date
Hemorrhage	United States	Portola Pharmaceuticals LLC	03 May 2018
Hemorrhage	United States	AstraZeneca AB	03 May 2018

Developing

10 top R&D records.

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Indication	Highest Phase	Country/Location	Organization	Date
Massive hemorrhage	Phase 3	-	AstraZeneca PLC	02 Aug 2024

Clinical Result

Indication

Phase

Evaluation

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Study	Phase	Population	Analyzed Enrollment	Group	Results	Evaluation	Publication Date


ATS2025	Not Applicable	Upper gastrointestinal hemorrhage	320	Andexanet Alpha	nolnateefg(shtnsaipxk): HR = 1.5 (95% CI, 0.93 - 2.33), P-Value = 0.09 View more	Negative	16 May 2025
				Protein Complex Concentrate (PCC)
NCT03661528 (ANNEXA-I Biomarker Substudy \| ANNEXA-I, CTgov)	Phase 4	Intracranial Hemorrhages	530	andexanet alfa (Andexanet Alfa)	ekigkptmbj = lrmamjxqjx ioeitaaqel (kekxsjtpjn, msphsezeod - mtloazukiu) View more	-	03 Jul 2024
				Usual Care (Usual Care)	ekigkptmbj = vljkdhbimd ioeitaaqel (kekxsjtpjn, kgbfosbpnh - vennqzawow) View more
NCT03661528 (Pubmed) Manual	Phase 4	Cerebral Hemorrhage	530	Andexanet alfa	bscuymoirk(jgmossgukf) = ibcplydppl jefhwjncvs (xogjqsqrin ) View more	Positive	16 May 2024
				Andexanet (Usual care)	bscuymoirk(jgmossgukf) = ebkfoumnsm jefhwjncvs (xogjqsqrin ) View more
ISTH2023	Not Applicable	Hemorrhage	-	Andexanet alfa	vupxbflrdo(afemravvie) = crxrqcqgsw ebfveotxgd (zuyhnlgevg )	-	24 Jun 2023
				4-Factor Prothrombin Complex Concentrate (4F-PCC)	vupxbflrdo(afemravvie) = xwkzvaumvb ebfveotxgd (zuyhnlgevg )
ISTH2023	Not Applicable	Hemorrhage factor Xa (FXa) inhibitors rivaroxaban \| apixaban	-	Andexanet alfa	gwtsuoguun(teebjbfpie) = rdshfgjmqp fucmeejbuo (seicjrxlkn ) View more	-	24 Jun 2023
				4-factor prothrombin complex concentrate	gwtsuoguun(teebjbfpie) = ktdmlqwtdn fucmeejbuo (seicjrxlkn ) View more
NCT02329327 (ANNEXA-4, Pubmed \| Circulation)	Phase 3	Hemorrhage	479	Andexanet alfa	cyxzrfutta(kywhoqhknt) = dmvuvhestx nckgeqijtp (dnatmcvzta, 10.0)	-	20 Feb 2023
NCT02329327 (Pubmed \| Crit Care)	Phase 3	Intracranial Hemorrhages	-	Andexanet alfa	ljgazrrguc(ieasprinxt) = ywhotksiqq dlyuxaiget (dhaapybigy ) View more	-	16 Jun 2022
				Four-factor prothrombin complex concentrate (4F-PCC)	ljgazrrguc(ieasprinxt) = xrxmpzgllu dlyuxaiget (dhaapybigy ) View more
NCT02329327 \| NCT03093233 (ANNEXA-4, Pubmed \| Stroke)	Phase 3	Cerebral Hemorrhage	182	Andexanet alfa	zvugpbdsxt(ogyryqdeey) = aonfwddmue ubyzyfhflp (sisxrjddub )	-	14 Oct 2021
				Usual care (primarily administration of prothrombin complex concentrates)	zvugpbdsxt(ogyryqdeey) = rmharbmzfi ubyzyfhflp (sisxrjddub )
ISC2021	Not Applicable	Hemorrhage	-	Idarucizumab	kywvhespwp(ssdwgfueww) = omyqiatvss kchcszihbb (qxthvpvwmf )	-	01 Mar 2021
				Andexanet Alfa	kywvhespwp(ssdwgfueww) = gpexgvhhbr kchcszihbb (qxthvpvwmf )
NCT03330457 (CTgov)	Phase 2	Hemorrhage	18	Andexanet alfa (bolus)+Betrixaban 80 mg PO QD (Cohort 1 Bertrixaban/Andexanet)	lkyulwifar(fllxgbcuow) = nhsmraogce cuoqlpifqn (rlsoxpyfri, 7.453) View more	-	19 Aug 2020
				Andexanet alfa (bolus)+Betrixaban 80 mg PO QD (Cohort 1 Bertrixaban/Placebo)	lkyulwifar(fllxgbcuow) = hjkbijjpyx cuoqlpifqn (rlsoxpyfri, 10.090) View more

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