MOFFITT HEME/ONC REPORT PEARLS 5/12/17: Warfarin-Related Bleeding!

Hey Everyone! Thanks to Matt for presenting the case of an elderly man with heart failure and valve replacement on warfarin presenting with a fall and found to have severe vital sign abnormalities and INR of 13! Pearls below:

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Top Pearls:

  1. 1st steps in warfarin-related bleeding: stabilize and give IV vitamin K.
  2. PCC is generally preferred over FFP where available. Give IV vitamin K too!!

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For those who want more info:

Rachel Stern wrote excellent pearls on supratherapeutic INR in patients on warfarin, see below:

https://ucsfmed.wordpress.com/2017/02/04/warfarin-supra-therapeutic-inr/

Here’s some additional info on warfarin reversal agents:

If no bleeding:

IV agents should only be needed if bleeding is present. Otherwise, you can get by with just holding the warfarin, and giving PO vitamin K if INR is very elevated. In the updated 2012 ACCP guidelines, the threshold for giving PO vitamin K for an elevated INR in the absence of bleeding was changed from >9.0 to >10.0.

If bleeding:

IV vitamin K: Works within 12-24 hours. IV and PO vitamin K reverse INR equally effectively, IV just works faster. **ALWAYS give IV vitamin K ASAP if bleeding on warfarin.**

Dosing: 5-10 mg IV no faster than 1 mg/min to reduce anaphylaxis risk. Can repeat every 12 hours if INR remains elevated.

PCC: Prothrombin complex concentrates, contain clotting factors, protein C/S and low doses of heparin to prevent premature clotting factor activation. Corrects INR faster than FFP and with less volume, often within 10 minutes. Effect is transient (hours) so must administer IV vitamin K simultaneously. 5x more expensive than FFP.

  • Kcentra: 4 factor unactivated (II, VII, IX, X)
  • Bebulin: 3 factor unactivated (II, IX, X)
  • FEIBA: 4 factor activated (II, VII, IX, X) [“factor eight inhibitor activity bypassing agent”] used primarily in hemophilia patients or DOAC reversal, not used routinely in warfarin bleeding.

No great evidence directly comparing 4 vs 3 factor concentrates, but generally 4 factor concentrates are preferred. Can be thrombogenic.

Dosing: Fixed dosing non-inferior to weight-based dosing; give 1500-2000 IU at 100 IU/min.

*Pearl: ACCP 2012 guidelines recommend PCC over FFP for warfarin-associated bleeding.

FFP: Fresh frozen plasma, contains all clotting factors at physiologic concentrations. Takes 30 mins or more to give one unit, so takes several hours to administer whole dose. Must be ABO compatible. Effect is transient (hours) so must administer IV vitamin K simultaneously.

Dosing: Start with 4 units (1L volume), up to 8 units are often required for full reversal.

rFVIIa: Recombinant activated factor 7. Works within 10 minutes. Effect is transient (hours) so must administer IV vitamin K simultaneously. Not typically given as monotherapy because does not replace other factors. Can be thrombogenic.

Dosing: 20 mcg/kg bolus

See summary table below:

Warfarin bleeding

 

Evernote: https://www.evernote.com/shard/s272/sh/93445eda-f71a-4bee-952e-b6ffacd966db/8899e5c0b3e5e16ee2500ff81a9293f9

Have a great day everyone!

SamMy

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2 thoughts on “MOFFITT HEME/ONC REPORT PEARLS 5/12/17: Warfarin-Related Bleeding!”

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