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Reversal strategies and outcomes in patients with atrial fibrillation and warfarin-associated intracranial hemorrhage. J Stroke Cerebrovasc Dis 2020; 29:104903. [PMID: 32689580 DOI: 10.1016/j.jstrokecerebrovasdis.2020.104903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 04/14/2020] [Accepted: 04/22/2020] [Indexed: 11/24/2022] Open
Abstract
PURPOSE Evaluate reversal strategies in atrial fibrillation (AF) patients with warfarin-associated intracranial hemorrhage (ICH) in clinical care. MATERIALS AND METHODS Observational cohort of AF patients with warfarin-associated ICH at two referral hospitals (2007-2010), with patient features, reversal agents, and outcomes collected from medical records. RESULTS Among 498 ICH patients 403 received fresh frozen plasma (FFP) without 3-factor prothrombin complex concentrates (PCCs) or recombinant factor VIIa (rFVIIa), 65 received PCCs or rFVIIa, mostly with FFP, and 30 received no acute reversal agents. Median time from presentation to reversal agent administration was 3.4 h (IQR 2.3-5.3). INR was reversed to ≤1.4 by 6 h post-presentation in 46% of patients receiving PCCs/rFVIIa versus 15% receiving FFP alone (p<0.0001). Among PCCs/rFVIIa recipients, 31% died in-hospital vs. 24% receiving FFP alone (p=0.27). Adjusted OR for death accounting for age and Glasgow Coma Score was 0.78 (0.36-1.69) for PCCs/rFVIIa vs FFP only and 1.16 (0.59-2.27) comparing those reaching vs. not reaching INR ≤ 1.4 at 6 h. CONCLUSIONS Treatment with PCCs/rFVIIa led to faster INR reversal than treatment with FFP alone. Neither treatment with PCCs/rFVIIa nor rapid INR reversal was associated with improved survival. Delays receiving PCCs may largely eliminate the benefit of treatment.
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Kim C, Cottingham L, Eberwein K, Komyathy K, Ratliff PD. Comparison of Hemostatic Outcomes in Patients Receiving Fixed-Dose vs. Weight-Based 4-Factor Prothrombin Complex Concentrate. J Emerg Med 2020; 59:25-32. [PMID: 32536491 DOI: 10.1016/j.jemermed.2020.04.049] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 04/28/2020] [Accepted: 04/28/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Four-factor prothrombin complex concentrate (4F-PCC) is a blood coagulation product indicated for urgent reversal of warfarin. Currently there are no studies using 4F-PCC as a fixed dose to achieve hemostasis with warfarin as well as direct factor Xa inhibitors. OBJECTIVES The objective of this study was to evaluate the efficacy and safety of 4F-PCC administration using a fixed dose of approximately 2000 factor IX units to achieve hemostasis in anticoagulated patients, compared with weight-based therapy. METHODS This single-center, retrospective cohort study was performed at a 433-bed tertiary care hospital in central Kentucky. Patients from January 1, 2014 to December 31, 2018 were included if they were 18 years or older and received 4F-PCC for hemostasis of oral anticoagulation. Efficacy was assessed by determining if clinically effective hemostasis was achieved after receiving a fixed-dose vs. a weight-based dose of 4F-PCC. RESULTS Seventy-two patients were included in the study. Thirty-eight received weight-based dosing, compared with 34 receiving a fixed dose. Results yielded no statistical difference in clinically effective hemostasis using a fixed-dose vs. weight-based dosing, 91.2% and 78.9%, respectively (p = 0.150). There was no significant difference in adverse events, length of stay, or in-hospital mortality between groups; however, significant acquisition cost savings was realized. CONCLUSIONS A fixed-dose regimen of approximately 2000 factor IX units of 4F-PCC may be a reasonable approach to achieve hemostasis in patients receiving warfarin or factor Xa inhibitors. Additionally, utilization of a fixed-dose regimen may lead to significant acquisition cost savings for facilities.
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Affiliation(s)
- Caroline Kim
- Department of Pharmacy Services, Saint Joseph Hospital, Lexington, Kentucky
| | - Lauren Cottingham
- Department of Pharmacy Services, Saint Joseph Hospital, Lexington, Kentucky
| | - Kip Eberwein
- Department of Pharmacy Services, Saint Joseph Hospital, Lexington, Kentucky
| | - Kelsey Komyathy
- Department of Pharmacy Services, Duke University Hospital, Durham, North Carolina
| | - Patrick D Ratliff
- Department of Pharmacy Services, Saint Joseph Hospital, Lexington, Kentucky
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Agarwal P, Abdullah KG, Ramayya AG, Nayak NR, Lucas TH. A Retrospective Propensity Score-Matched Early Thromboembolic Event Analysis of Prothrombin Complex Concentrate vs Fresh Frozen Plasma for Warfarin Reversal Prior to Emergency Neurosurgical Procedures. Neurosurgery 2019; 82:877-886. [PMID: 29106685 DOI: 10.1093/neuros/nyx327] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Accepted: 05/16/2017] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Reversal of therapeutic anticoagulation prior to emergency neurosurgical procedures is required in the setting of intracranial hemorrhage. Multifactor prothrombin complex concentrate (PCC) promises rapid efficacy but may increase the probability of thrombotic complications compared to fresh frozen plasma (FFP). OBJECTIVE To compare the rate of thrombotic complications in patients treated with PCC or FFP to reverse therapeutic anticoagulation prior to emergency neurosurgical procedures in the setting of intracranial hemorrhage at a level I trauma center. METHODS Sixty-three consecutive patients on warfarin therapy presenting with intracranial hemorrhage who received anticoagulation reversal prior to emergency neurosurgical procedures were retrospectively identified between 2007 and 2016. They were divided into 2 cohorts based on reversal agent, either PCC (n = 28) or FFP (n = 35). The thrombotic complications rates within 72 h of reversal were compared using the χ2 test. A multivariate propensity score matching analysis was used to limit the threat to interval validity from selection bias arising from differences in demographics, laboratory values, history, and clinical status. RESULTS Thrombotic complications were uncommon in this neurosurgical population, occurring in 1.59% (1/63) of treated patients. There was no significant difference in the thrombotic complication rate between groups, 3.57% (1/28; PCC group) vs 0% (0/35; FFP group). Propensity score matching analysis validated this finding after controlling for any selection bias. CONCLUSION In this limited sample, thrombotic complication rates were similar between use of PCC and FFP for anticoagulation reversal in the management of intracranial hemorrhage prior to emergency neurosurgical procedures.
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Affiliation(s)
- Prateek Agarwal
- Department of Neurosurgery, Center for Neuroengineering and Therapeutics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kalil G Abdullah
- Department of Neurosurgery, Center for Neuroengineering and Therapeutics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ashwin G Ramayya
- Department of Neurosurgery, Center for Neuroengineering and Therapeutics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nikhil R Nayak
- Department of Neurosurgery, Center for Neuroengineering and Therapeutics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Timothy H Lucas
- Department of Neurosurgery, Center for Neuroengineering and Therapeutics, University of Pennsylvania, Philadelphia, Pennsylvania
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Ostermann H, von Heymann C. Prothrombin complex concentrate for vitamin K antagonist reversal in acute bleeding settings: efficacy and safety. Expert Rev Hematol 2019; 12:525-540. [PMID: 31159607 DOI: 10.1080/17474086.2019.1624520] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Introduction: Current guidelines recommend the administration of prothrombin complex concentrate in combination with vitamin K for normalization of coagulation in patients presenting with vitamin K antagonist-associated major bleeding, but until recently no adequately powered comparative trials had been conducted to support these recommendations. In this article, the authors review the evidence from studies assessing prothrombin complex concentrate treatment in these patients. Areas covered: A PubMed search (spanning January 1900 to September 2018) was conducted using the following search terms: prothrombin complex concentrate* AND (warfarin or (vitamin K antagonist*)), and papers relevant to major hemorrhagic events were identified; results from studies that used a randomized controlled trial (RCT) or a prospective design are presented here. Overall, the identified studies support the current guideline recommendations and indicate that prothrombin complex concentrates have at least similar safety profiles to other treatment options, such as fresh frozen plasma and recombinant activated factor VII. Expert opinion: It is hoped that the results from studies discussed here will inform future guideline updates; however, local clinical practice may also occasionally act as a barrier to adoption of guideline recommendations. There is an urgent need for further RCTs/prospective trials directly comparing PCC and plasma administration in acute bleeding settings.
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Affiliation(s)
- Helmut Ostermann
- a Department of Hematology/Oncology , Ludwig-Maximilians-Universität München , Munich , Germany
| | - Christian von Heymann
- b Department of Anesthesia, Intensive Care Medicine, Emergency Medicine and Pain Therapy , Vivantes Klinikum im Friedrichshain , Berlin , Germany
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Di Fusco SA, Lucà F, Benvenuto M, Iorio A, Fiscella D, D'Ascenzo F, Madeo A, Colivicchi F, Di Lenarda A, Gulizia MM. Major bleeding with old and novel oral anticoagulants: How to manage it. Focus on reversal agents. Int J Cardiol 2018; 268:75-79. [DOI: 10.1016/j.ijcard.2018.05.060] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Revised: 04/19/2018] [Accepted: 05/18/2018] [Indexed: 12/13/2022]
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Imberti D, Permunian ET, Croci E, Ageno W, Dentali F. Risk factors for suboptimal efficacy of 3-factor prothrombin complex concentrates in emergency VKA anticoagulation reversal. Thromb Haemost 2017; 112:621-3. [DOI: 10.1160/th13-10-0851] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2013] [Accepted: 04/23/2014] [Indexed: 11/05/2022]
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Hedges A, Coons JC, Saul M, Smith RE. Clinical effectiveness and safety outcomes associated with prothrombin complex concentrates. J Thromb Thrombolysis 2017; 42:6-10. [PMID: 26685667 DOI: 10.1007/s11239-015-1321-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Prothrombin complex concentrates (PCCs) are indicated for urgent reversal of warfarin and used for reversal of novel oral anticoagulants, in patients with acute major bleeding or need for an urgent procedure. The research goal was to evaluate effectiveness and safety outcomes with PCC usage at our institution. A retrospective review of electronic medical records identified patients that received a PCC commercially available in the United States (KCentra(®) or Profilnine(®)) at twelve hospitals in a tertiary care health system from July 1, 2013 to April 30, 2014. A total of 193 patients received PCC, of which 184 patients received four-factor PCC. The patient population was 48 % male and 75 % Caucasian, with a mean age of 73 years old. Clinical outcomes of interest included time to achieve a target INR ≤1.3, time to Hgb >7 g/dL, and incidence of thromboembolism. A total of 143 patients were on warfarin (74.1 %) at baseline, whereas 18 patients (9.3 %) were taking a novel anticoagulant. Target INR of ≤1.3 was achieved in 125 patients (65.8 %), within a median time of 8.03 h (IQR 3.38-34.07). Among patients with a baseline Hgb <7 g/L (n = 13), the median time to Hgb >7 g/dL was 8.48 h (IQR 6.95-13.00). Eight patients (4.1 %) developed an acute venous thromboembolism following PCC administration. INR reversal was achieved in approximately two-thirds of patients, with a low incidence of venous thromboembolism. Four-factor PCC is a viable alternative to plasma.
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Affiliation(s)
- Ashley Hedges
- Department of Pharmacy Services, University of Utah Hospital and Clinics, 50 N Medical Drive, Salt Lake City, UT, 84132, USA
| | - James C Coons
- University of Pittsburgh School of Pharmacy, 727 Salk Hall, 3501 Terrace Street, Pittsburgh, PA, 15261, USA.
| | - Melissa Saul
- Department of Medicine, University of Pittsburgh, 1216 Kaufman Building, Pittsburgh, PA, 15213, USA
| | - Roy E Smith
- Hematology/Oncology Division, UPMC Presbyterian-Shadyside Hospital, 5150 Centre Avenue, Pittsburgh, PA, 15232, USA
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Risk of Venous Thromboembolism After Receiving Prothrombin Complex Concentrate for Warfarin-associated Intracranial Hemorrhage. J Emerg Med 2016; 50:1-6. [DOI: 10.1016/j.jemermed.2015.07.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Revised: 07/09/2015] [Accepted: 07/21/2015] [Indexed: 01/29/2023]
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Khorsand N, Majeed A, Sarode R, Beyer-Westendorf J, Schulman S, Meijer K. Assessment of effectiveness of major bleeding management: proposed definitions for effective hemostasis: communication from the SSC of the ISTH. J Thromb Haemost 2016; 14:211-4. [PMID: 26391431 DOI: 10.1111/jth.13148] [Citation(s) in RCA: 73] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Accepted: 09/04/2015] [Indexed: 12/27/2022]
Affiliation(s)
- N Khorsand
- Department of Hematology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
- Central Hospital Pharmacy, the Hague, the Netherlands
| | - A Majeed
- Coagulation Unit, Hematology Center, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden
| | - R Sarode
- Division of Transfusion Medicine and Hemostasis, Department of Pathology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - J Beyer-Westendorf
- Thrombosis Research Unit, Center of Vascular Diseases, Dresden University Hospital 'Carl Gustav Carus', Dresden, Germany
| | - S Schulman
- Coagulation Unit, Hematology Center, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - K Meijer
- Department of Hematology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
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Bernardi E, Imberti D, Ferrari A. Management Strategies for Vitamin K Antagonists Reversal in Patients With Major Bleeding: A Survey of Italian Emergency Departments. Clin Appl Thromb Hemost 2015; 23:40-44. [PMID: 26239314 DOI: 10.1177/1076029615598219] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE Emergency physicians frequently deal with patients on vitamin K antagonists (VKAs) suffering major bleeding events, and rapid reversal of anticoagulation in this setting is of paramount importance. In Italy, given the absence of specific national guidelines, local policies are likely to differ, possibly impacting on clinical outcomes. We decided to perform a telephone survey among Italian emergency physicians to evaluate management strategies for VKAs reversal in patients with major bleeding. METHODS We conducted a computer-assisted, 10-minute telephone survey of 15 questions, focusing on the local prevalence, assessment, and management strategies of major and intracranial hemorrhage (ICH) occurring in patients on VKAs. We planned to interview a sample of 320 Italian emergency physicians. Institutions from all geographic areas of Italy were to participate in the survey. RESULTS Of the 320 physicians contacted, 150 (47%) completed the survey, 95% being employed in public hospitals. Focusing on ICH, only 29% of the responders stated they would reverse anticoagulation irrespective of the international normalized ratio value, and only 27% would use prothrombin-complex concentrate as first-line agent. In patients needing urgent neurosurgical operation, less than 50% would administer prothrombin-complex concentrate before surgery. CONCLUSION The average knowledge of management strategies for reversal of anticoagulation displayed by Italian emergency physicians appears to be unsatisfactory. The need for an extensive educational program and for the implementation of specific guidelines, possibly endorsed by Scientific Societies, cannot be underemphasized.
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Affiliation(s)
| | - Davide Imberti
- UOC Medicina Interna Centro Emostasi e Trombosi, Ospedale "Guglielmo da Saliceto", Piacenza, Italy
| | - Annamaria Ferrari
- Dipartimento Emergenza-Urgenza, Azienda Ospedaliera di Reggio Emilia, Reggio Emilia, Italy
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Khorsand N, Kooistra HA, van Hest RM, Veeger NJ, Meijer K. A systematic review of prothrombin complex concentrate dosing strategies to reverse vitamin K antagonist therapy. Thromb Res 2015; 135:9-19. [DOI: 10.1016/j.thromres.2014.11.019] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2014] [Revised: 11/12/2014] [Accepted: 11/16/2014] [Indexed: 11/16/2022]
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Tilton R, Michalets EL, Delk B, Sutherland SE, Ramming SA. Outcomes Associated With Prothrombin Complex Concentrate for International Normalized Ratio Reversal in Patients on Oral Anticoagulants With Acute Bleeding. Ann Pharmacother 2014; 48:1106-1119. [PMID: 24899340 DOI: 10.1177/1060028014537897] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Management of bleeding in patients on oral anticoagulants (OACs) is crucial in optimizing outcomes. No large studies examine 3-factor prothrombin complex concentrate (PCC) for OAC reversal. OBJECTIVE To assess outcomes after administration of 3-factor PCC for reversal of international normalized ratio (INR). METHOD We conducted an institutional review board-approved retrospective cohort study in all patients admitted to our level II trauma center over a 5-year period from 2007 to 2012 who received PCC for INR reversal and bleeding management. The primary outcome was assessment of efficacy as measured by achievement of INR < 1.5. Secondary objectives were to evaluate: factors associated with achievement of target INR, cessation of bleeding, mortality, outcome differences with or without fresh frozen plasma (FFP) or protocol utilization, safety, and cost. RESULT A total of 403 patients were evaluated. Target INR was achieved in 88.8% of patients and was influenced by baseline INR. Associated factors were younger age (P = 0.02), utilization of the institution's protocol (P < 0.01), and concomitant administration of vitamin K (P < 0.01). Concomitant FFP did not affect achievement. Bleeding cessation occurred in 333 (82.6%) patients, and 68 (16.9%) patients died. Patients who achieved target INR were more likely to have bleeding cessation (P < 0.01). The odds of survival for those who reached target INR was 3.8 times greater (P < 0.01). The incidence of thromboembolism was 3.7%. CONCLUSION Three-factor PCC administration with IV vitamin K was effective for INR reversal and bleeding cessation and should continue to be a mainstay of therapy pending head-to-head outcome and cost comparisons with 4-factor products.
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Affiliation(s)
- Ryan Tilton
- Mission Health System Department of Pharmacy, Asheville, NC, USA
| | - Elizabeth Landrum Michalets
- Mission Health System Department of Pharmacy, Asheville, NC, USA University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Bethany Delk
- University of Virginia Health System Department of Pharmacy, Charlottesville, VA, USA
| | | | - Scott A Ramming
- Mission Health System and Carolina Mountain Emergency Medicine, Asheville, NC, USA
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Four-Factor Prothrombin Complex Concentrate for Urgent Reversal of Vitamin K Antagonists in Patients With Major Bleeding. Circulation 2013; 128:1179-81. [DOI: 10.1161/circulationaha.113.005107] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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