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Peterson ME, Jaynes MP, Berardi S, Morton C. Evaluation of modified fixed dose four-factor prothrombin complex concentrate for warfarin reversal. J Thromb Thrombolysis 2024:10.1007/s11239-024-02969-0. [PMID: 38581551 DOI: 10.1007/s11239-024-02969-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/08/2024] [Indexed: 04/08/2024]
Abstract
Non-activated four-factor prothrombin complex concentrate (4 F-PCC) has emerged as the preferred reversal strategy for patients on warfarin with life-threatening bleeding. Current dosing recommendations for 4 F-PCC require pre-treatment international normalized ratio (INR) and bodyweight values, resulting in ordering and administration delays. Studies have shown that alternative dosing regimens are safe and efficacious. This retrospective, single-center, pre- and post-protocol analysis was conducted to assess the efficacy of a pharmacist driven modified fixed-dose 4 F-PCC regimen versus package insert weight- and INR-based dosing regimen for warfarin reversal. The primary outcome was achievement of INR less than two. Secondary outcomes included dose and cost of 4 F-PCC, a time analysis, incidence of concomitant vitamin K administration, and incidence of thrombosis within seven days of 4 F-PCC. There were 195 patients included in the analysis, with 74 in the pre-cohort and 121 in the post-cohort. Baseline characteristics were similar between cohorts with the most common indication for warfarin use being atrial fibrillation (48.6% versus 47.1%) and reversal being intracerebral hemorrhage (68.9% versus 43.0%). Achievement of the primary endpoint occurred in 92% versus 95% (p = 0.097) of patients. A statistically significant difference was seen between cohorts regarding median dose and cost of 4 F-PCC administered (p < 0.001). Eleven thromboembolic events occurred with three events in the pre-cohort and eight events in the post-cohort (p = 0.453). A fixed-dose of 1500IU of 4 F-PCC was effective in reversing INR to less than two in most patients regardless of reversal indication with minimal thrombotic risks.
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Affiliation(s)
- Meghan E Peterson
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, 1211 Medical Center Drive, B-131 VUH, Nashville, TN, 37232, USA.
| | - Megan P Jaynes
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, 1211 Medical Center Drive, B-131 VUH, Nashville, TN, 37232, USA
| | - Sarah Berardi
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, 1211 Medical Center Drive, B-131 VUH, Nashville, TN, 37232, USA
| | - Colleen Morton
- Division of Hematology/Oncology, Vanderbilt-Ingram Cancer Center, Nashville, TN, USA
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2
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Curcio R, Paolucci F, Miano N, Pirera E, Monaco C. Should prothrombin complex concentrate be given to all patients with trauma at risk of massive transfusion? Intern Emerg Med 2024; 19:557-559. [PMID: 38114850 DOI: 10.1007/s11739-023-03485-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 11/07/2023] [Indexed: 12/21/2023]
Affiliation(s)
- Rosa Curcio
- Unit of Internal Medicine, ''Santa Maria'' University Hospital, P.Le Tristano Di Ioannuccio, 1, 05100, Terni, Italy.
| | - Fernanda Paolucci
- Department of Internal Medicine, Clinica Medica, AOUM, Ancona, Italy
| | - Nicoletta Miano
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Edoardo Pirera
- Department of Promoting Health, Maternal-Infant, Excellence and Internal and Specialized Medicine (Promise) G. D'Alessandro, University of Palermo, Palermo, Italy
| | - Cinzia Monaco
- General Medicine, IRCCS Sacro Cuore Don Calabria, Negrar, Verona, Italy
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Townsend B, Slechta J, Gilbert BW. Prothrombin complex concentrate administration timing in warfarin-associated intracranial hemorrhage. Am J Emerg Med 2024; 76:136-139. [PMID: 38071882 DOI: 10.1016/j.ajem.2023.11.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 11/17/2023] [Accepted: 11/18/2023] [Indexed: 01/22/2024] Open
Abstract
INTRODUCTION Guidelines recommend "rapid" and "urgent" reversal of anticoagulation for warfarin-associated intracranial hemorrhage (ICH) treatment; however, they do not specify goals for time-to-administration. There are limited studies evaluating time to reversal, or international normalized ratio (INR) correction, on hematoma expansion and outcomes in intervals of <4 h. The purpose of this study was to evaluate the association of 4-factor prothrombin concentrate (4F-PCC) time-to-administration on rates of achieving effective hemostasis, determined by hematoma expansion, for treatment of warfarin-associated ICH. METHODS This was a retrospective, observational, single center study performed at a large community teaching hospital. Patients were stratified into three groups based on time of CT diagnosis of ICH to administration of 4F-PCC: <45 min, 45-90 min, and >90 min. The primary outcome was rates of achieving effective hemostasis in each group defined as a ≤20% increase in hematoma volume as estimated by a radiologist. RESULTS A total of 227 patients were screened for inclusion with ultimately 39 being included. Baseline characteristics were similar between groups. The primary outcome was not significantly different among groups stratified by time to 4F-PCC administration of <45 min, 45-90 min, and >90 min (85.7% vs 73.3% vs 90%, p value 0.514). There was no difference among secondary outcomes between groups including in-hospital mortality, hospital length of stay (LOS), and intensive care unit LOS. CONCLUSION There was no association with time-to-administration of 4F-PCC on rates of hemostasis achievement, defined as hematoma expansion of ≤20%, identified in this study.
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Affiliation(s)
- Brock Townsend
- Pharmacy department, Wesley Medical Center, 550 N Hillside St, Wichita, KS 67214, United States of America.
| | - Joe Slechta
- Pharmacy department, Wesley Medical Center, 550 N Hillside St, Wichita, KS 67214, United States of America
| | - Brian W Gilbert
- Pharmacy department, Wesley Medical Center, 550 N Hillside St, Wichita, KS 67214, United States of America
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Viana P, Relvas JH, Persson M, Cabral TDD, Persson JE, de Oliveira JS, Bonow P, Freire CVS, Amaral S. Prothrombin Complex Concentrate versus Fresh Frozen Plasma in Adult Patients Undergoing Cardiac Surgery: A Systematic Review and Meta-Analysis. J Chest Surg 2024; 57:25-35. [PMID: 37994088 DOI: 10.5090/jcs.23.081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 09/05/2023] [Accepted: 09/28/2023] [Indexed: 11/24/2023] Open
Abstract
Background Prothrombin complex concentrate (PCC) and fresh frozen plasma (FFP) are commonly used to manage bleeding in patients during cardiac surgery. However, the relative efficacy and safety of these 2 strategies remain uncertain. Methods MEDLINE, Embase, and Cochrane were searched for studies comparing PCC and FFP in patients who underwent cardiac surgery complicated by bleeding. Review Manager (RevMan) ver. 5.4 (Nordic Cochrane Centre, The Cochrane Collaboration) was used for statistical analysis. Binary and continuous outcomes were compared using pooled risk ratios and mean differences, respectively. The meta-analysis protocol was registered in the International Prospective Register of Systematic Reviews under protocol number CRD42022379144. Results We included 8 studies with 1,500 patients, of whom 613 (40.9%) received PCC. The mean follow-up period ranged from 28 to 90 days. The PCC group had significantly lower chest tube drainage at 24 hours (mean difference [MD], -148.50 mL; 95% CI, -253.02 to -43.99 mL; p=0.005; I2=42%). Fewer units of red blood cells (RBCs) were transfused within the first 24 hours (MD, -1.02 units; 95% CI, -1.81 to -0.24 units; p=0.01; I2=56%), and fewer patients required RBC transfusion within the first 24 hours (risk ratio, 0.85; 95% CI, 0.78-0.93; p<0.007; I2=45%) in the PCC group. There were no statistically significant differences in secondary outcomes. Nonetheless, a subgroup analysis of randomized controlled trials failed to corroborate the results obtained from the main analysis. Conclusion Our findings suggest that PCC can be effective, without increased adverse events, when compared with FFP in patients undergoing cardiac surgery complicated by bleeding.
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Affiliation(s)
- Patricia Viana
- Department of Medicine, Universidade do Extremo Sul Catarinense, Criciuma, Brazil
| | | | - Marina Persson
- Department of Medicine, Universidade Federal de Pelotas, Pelotas, Brazil
| | | | | | | | - Paulo Bonow
- Department of Medicine, Universidade Federal de Pelotas, Pelotas, Brazil
| | | | - Sara Amaral
- Department of Anesthesiology, Universidade Nova de Lisboa, Lisbon, Portugal
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Hannadjas I, James A, Davenport R, Lindsay C, Brohi K, Cole E. Prothrombin complex concentrate (PCC) for treatment of trauma-induced coagulopathy: systematic review and meta-analyses. Crit Care 2023; 27:422. [PMID: 37919775 PMCID: PMC10621181 DOI: 10.1186/s13054-023-04688-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 10/14/2023] [Indexed: 11/04/2023] Open
Abstract
BACKGROUND Trauma-induced coagulopathy (TIC) is common in trauma patients with major hemorrhage. Prothrombin complex concentrate (PCC) is used as a potential treatment for the correction of TIC, but the efficacy, timing, and evidence to support its use in injured patients with hemorrhage are unclear. METHODS A systematic search of published studies was performed on MEDLINE and EMBASE databases using standardized search equations. Ongoing studies were identified using clinicaltrials.gov. Studies investigating the use of PCC to treat TIC (on its own or in combination with other treatments) in adult major trauma patients were included. Studies involving pediatric patients, studies of only traumatic brain injury (TBI), and studies involving only anticoagulated patients were excluded. Primary outcomes were in-hospital mortality and venous thromboembolism (VTE). Pooled effects of PCC use were reported using random-effects model meta-analyses. Risk of bias was assessed for each study, and we used the Grading of Recommendations Assessment, Development, and Evaluation to assess the quality of evidence. RESULTS After removing duplicates, 1745 reports were screened and nine observational studies and one randomized controlled trial (RCT) were included, with a total of 1150 patients receiving PCC. Most studies used 4-factor-PCC with a dose of 20-30U/Kg. Among observational studies, co-interventions included whole blood (n = 1), fibrinogen concentrate (n = 2), or fresh frozen plasma (n = 4). Outcomes were inconsistently reported across studies with wide variation in both measurements and time points. The eight observational studies included reported mortality with a pooled odds ratio of 0.97 [95% CI 0.56-1.69], and five reported deep venous thrombosis (DVT) with a pooled OR of 0.83 [95% CI 0.44-1.57]. When pooling the observational studies and the RCT, the OR for mortality and DVT was 0.94 [95% CI 0.60-1.45] and 1.00 [95% CI 0.64-1.55] respectively. CONCLUSIONS Among published studies of TIC, PCCs did not significantly reduce mortality, nor did they increase the risk of VTE. However, the potential thrombotic risk remains a concern that should be addressed in future studies. Several RCTs are currently ongoing to further explore the efficacy and safety of PCC.
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Affiliation(s)
- Ioannis Hannadjas
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, England
| | - Arthur James
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, England.
- GRC 29, AP-HP, DMU DREAM, Department of Anaesthesiology and Critical Care, Pitié-Salpêtrière Hospital, Sorbonne University, 47-83 Boulevard de l'Hôpital, 75013, Paris, France.
| | - Ross Davenport
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, England
| | - Charlotte Lindsay
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, England
| | - Karim Brohi
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, England
| | - Elaine Cole
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, England
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Orban JE, Ruckel C, Harlan S. Concomitant andexanet alfa and 4 F-PCC for Factor Xa inhibitor associated intracranial hemorrhage. Clin Neurol Neurosurg 2023; 233:107908. [PMID: 37515854 DOI: 10.1016/j.clineuro.2023.107908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Revised: 07/15/2023] [Accepted: 07/17/2023] [Indexed: 07/31/2023]
Abstract
Andexanet alfa is the only FDA approved drug for acute reversal of life-threatening bleeding associated with oral factor Xa inhibitor agents. The case series investigates clinical outcomes of four patients receiving concomitant Andexanet alfa and Four Factor Prothrombin Concentrate Complex (4 F-PCC) for acute reversal of intracranial hemorrhage. Following administration, effective hemostasis was achieved in two patients (50%) and one patient (25%) experienced an acute ischemic stroke. Two patients (50%) expired prior to discharge without achieving hemostasis. This case series serves to further expand the limited data on the concomitant administration of Andexanet alfa and 4 F-PCC.
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Affiliation(s)
- James E Orban
- Lexington Medical Center, 2720 Sunset Blvd, West Columbia, SC, 29169, USA.
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Pon G, Pelsue B, Reddy ST, Parsha K, Zhang X, Gulbis B, Barreto A, Savitz SI, Escobar M, Allison TA. Hemostatic efficacy of four factor prothrombin complex concentrate in intracerebral hemorrhage patients receiving warfarin vs. factor Xa inhibitors. Thromb Res 2023; 229:46-52. [PMID: 37406569 DOI: 10.1016/j.thromres.2023.06.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 06/04/2023] [Accepted: 06/20/2023] [Indexed: 07/07/2023]
Abstract
INTRODUCTION 4-F PCC is administered for reversal of factor Xa inhibitor-associated coagulopathy despite a lack of quality evidence demonstrating hemostatic efficacy. The aim of this study was to evaluate the hemostatic efficacy of 4-F PCC in intracerebral hemorrhage patients who received factor Xa inhibitors versus warfarin. MATERIALS AND METHODS This was a multi-center, retrospective, observational cohort study at a large healthcare system. Patients taking warfarin received 4-F PCC 25-50 units/kg based on the presenting INR, while patients taking a factor Xa inhibitor received 35 units/kg. The primary outcome was the percentage of patients with good or excellent hemostatic efficacy as assessed by modified Sarode scale, with neurologic outcomes assessed as a secondary endpoint. Patients were included in the primary outcome population if they had a repeat CT scan within 24 h. RESULTS One hundred fifty-seven patients were included in the primary outcome population; [warfarin (n = 76), factor Xa inhibitors (n = 81)]. Hemostatic efficacy was 83 % in the warfarin group versus 75 % in the factor Xa inhibitor group (p = 0.24). The hemostatic efficacy risk difference between the groups was 7.6 % (95 % CI 5.1 %, 20.2 %). Good neurologic outcome (mRS 0-2) at discharge was 17 % in warfarin patients versus 12 % in the factor Xa inhibitor patients (p = 0.40). CONCLUSIONS There was no significant difference in hemostatic efficacy or clinical outcomes between patients taking warfarin or a factor Xa inhibitor following reversal with 4-F PCC. This study provides further support that 4-F PCC can be used for the reversal of factor Xa inhibitor-associated coagulopathy.
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Affiliation(s)
- Gregory Pon
- Department of Pharmacy, Memorial Hermann - Texas Medical Center, 6411 Fannin St, Houston, TX 77030, United States of America
| | - Brittany Pelsue
- Department of Pharmacy, Memorial Hermann - Texas Medical Center, 6411 Fannin St, Houston, TX 77030, United States of America
| | - Sujan Teegala Reddy
- Department of Neurology, McGovern Medical School at The University of Texas Health Science Center of Houston, 6431 Fannin St, Houston, TX 77030, United States of America; Mercy Hospital, Fort Smith, AR 72913, United States of America
| | - Kaushik Parsha
- Department of Neurology, McGovern Medical School at The University of Texas Health Science Center of Houston, 6431 Fannin St, Houston, TX 77030, United States of America; Division of Neurology, Baptist Memorial Hospital, Memphis TN 38120, United States of America
| | - Xu Zhang
- Center for Clinical and Translational Sciences, McGovern Medical School at The University of Texas Health Science Center of Houston, 7000 Fannin St, Houston, TX 77030, United States of America; Department of Internal Medicine, McGovern Medical School at The University of Texas Health Science Center of Houston, 6431 Fannin St, MSB 1.150, Houston, TX 77030, United States of America
| | - Brian Gulbis
- Department of Pharmacy, Memorial Hermann - Texas Medical Center, 6411 Fannin St, Houston, TX 77030, United States of America
| | - Andrew Barreto
- Department of Neurology, McGovern Medical School at The University of Texas Health Science Center of Houston, 6431 Fannin St, Houston, TX 77030, United States of America
| | - Sean I Savitz
- Department of Neurology, McGovern Medical School at The University of Texas Health Science Center of Houston, 6431 Fannin St, Houston, TX 77030, United States of America
| | - Miguel Escobar
- Department of Hematology, McGovern Medical School at The University of Texas Health, Science Center of Houston, 6410 Fannin St, STE 830, Houston, TX 77030, United States of America
| | - Teresa A Allison
- Department of Pharmacy, Memorial Hermann - Texas Medical Center, 6411 Fannin St, Houston, TX 77030, United States of America.
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Adkins BD, Shaim H, Abid A, Gonzalez A, DeAnda A, Yates SG. Four-factor prothrombin complex concentrate use for on-label versus off-label indications: a retrospective cohort study. J Thromb Thrombolysis 2023; 55:74-82. [PMID: 35699871 DOI: 10.1007/s11239-022-02671-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/26/2022] [Indexed: 11/27/2022]
Abstract
This study aimed to characterize the utilization of four-factor prothrombin complex concentrate (4F-PCC) at a tertiary academic medical center and evaluate the incidence of thromboembolic events (TEs) and mortality when used in an on-label versus off-label context. All medical records for consecutive patients having received 4F-PCC over 61-months were retrospectively evaluated. On-label indications for 4F-PCC were defined per FDA guidance, with the remaining indications considered off-label. Three hundred sixty-nine 4F-PCC doses were administered to 355 patients, with 46.6% of administrations classified as off-label. On-label and off-label groups demonstrated similar rates of TEs (16.2% vs. 14%). On-label patients receiving repeated administrations of 4F-PCC or with a post-administration INR ≤ 1.5 had a significantly higher incidence of TE. Off-label patients with a prior history of TE were more likely to develop a TE following 4F-PCC administration. Off-label patients also had a significantly higher 30-day mortality relative to on-label patients (29.1% versus 18.3%). In conclusion, in a large cohort of patients, observed rates of off-label 4F-PCC use were high. Underlying prothrombotic risk factors were predictive of TEs in off-label patients. Moreover, patients receiving off-label 4F-PCC demonstrated higher transfusion rates. Overall, our study findings suggest that the utilization of 4F-PCC in an off-label context may convey a significant risk to patients with uncertain clinical benefits.
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Affiliation(s)
- Brian D Adkins
- Division of Transfusion Medicine and Hemostasis, Department of Pathology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390, USA
| | - Hila Shaim
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Abdul Abid
- Department of Pathology, University of Texas Medical Branch, Galveston, TX, USA
| | - Adam Gonzalez
- Department of Pathology, University of Texas Medical Branch, Galveston, TX, USA
| | - Abe DeAnda
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, University of Texas Medical Branch, Galveston, TX, USA
| | - Sean G Yates
- Division of Transfusion Medicine and Hemostasis, Department of Pathology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390, USA.
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Spector H, McRae HL, Love T, Northam K, Refaai K, Rollins-Raval MA, Refaai MA. Reduced Time to Procedure for Gastrointestinal Bleeding After Warfarin Reversal With Four-Factor Complex Concentrate as Compared to Plasma. J Clin Med Res 2023; 15:51-57. [PMID: 36755762 PMCID: PMC9881491 DOI: 10.14740/jocmr4856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 01/16/2023] [Indexed: 01/26/2023] Open
Abstract
Background Bleeding is a serious adverse effect of vitamin K antagonists (VKAs). Anticoagulation reversal is required in some acute cases. This is usually accomplished by plasma transfusion or four-factor prothrombin complex concentrate (4F-PCC). The aim of this study was to gain insight into the clinical course of patients with gastrointestinal (GI) bleeding who require VKA reversal. Methods Medical records were collected from two centers from patients who presented to the emergency department (ED) for GI bleeding and received 4F-PCC or plasma for VKA reversal between January 2015 and December 2020. ED, hospital, intensive care unit (ICU) length of stay (LOS) as well as time from admission to GI procedure were determined. Results 4F-PCC patients (n = 49) as compared to plasma (n = 63) patients were found to have a greater number of comorbidities (average of 4.2 vs. 2.7 comorbidities/patient) and more ICU admissions (47% vs. 21%). Time to GI procedure was significantly decreased in the 4F-PCC group (median (interquartile range (IQR)) 19.47 (9.23 - 30.25) vs. 27.88 (21.38 - 45.00) h; P = 0.01). When adjusting for comorbidities, differences in time to GI procedures were also significant in favor of 4F-PCC regardless of any comorbidities (P = 0.014), in atrial fibrillation (P = 0.045) and in hypertension (P = 0.02). The 4F-PCC patients had shorter LOS in the ED and ICU. Conclusions Our study demonstrated that compared to plasma, 4F-PCC was utilized in more acutely ill patients with higher rates of comorbidities and ICU admission. Nevertheless, the patients who received 4F-PCC had faster access to GI procedure and shorter ED and ICU LOS.
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Affiliation(s)
- Hannah Spector
- Department of Pathology and Laboratory Medicine, Transfusion Medicine Division, University of Rochester Medical Center, Rochester, NY, USA
| | - Hannah L. McRae
- Department of Pathology and Laboratory Medicine, Transfusion Medicine Division, University of Rochester Medical Center, Rochester, NY, USA
| | - Tanzy Love
- Department of Biostatistics and Computational Biology, University of Rochester Medical Center, Rochester, NY, USA
| | - Kalynn Northam
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, NC, USA
| | - Khaled Refaai
- Department of Pathology and Laboratory Medicine, Transfusion Medicine Division, University of Rochester Medical Center, Rochester, NY, USA
| | | | - Majed A. Refaai
- Department of Pathology and Laboratory Medicine, Transfusion Medicine Division, University of Rochester Medical Center, Rochester, NY, USA,Corresponding Author: Majed A. Refaai, Department of Pathology and Laboratory Medicine, Transfusion Medicine Division, University of Rochester Medical Center, Rochester, NY 14642, USA.
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10
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Lipski M, Pasciolla S, Wojcik K, Jankowitz B, A Igneri L. Comparison of 4-factor prothrombin complex concentrate and andexanet alfa for reversal of apixaban and rivaroxaban in the setting of intracranial hemorrhage. J Thromb Thrombolysis 2022; 55:519-526. [PMID: 36566473 DOI: 10.1007/s11239-022-02752-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/05/2022] [Indexed: 12/26/2022]
Abstract
The purpose of this study was to evaluate and compare clinical outcomes in patients who experienced intracranial hemorrhage (ICH) while taking apixaban or rivaroxaban and were reversed with four-factor prothrombin complex concentrates (4F-PCC) or andexanet alfa (AA). This retrospective cohort included adult patients that received 4F-PCC or AA for the initial management of an apixaban- or rivaroxaban-associated ICH. A primary outcome of excellent or good hemostatic efficacy at 12 h post-reversal was assessed. Secondary outcomes evaluated were change in hematoma volume size at 12 h, functional status at discharge, need for surgical intervention or additional hemostatic agents post-reversal, new thrombotic event within 28 days, 28-day all-cause mortality, discharge disposition, and hospital and intensive care unit lengths of stay. A total of 70 patients were included (4F-PCC, n = 47; AA, n = 23). For the primary outcome analysis, 21 patients were included in the 4F-PCC group and 12 in the AA group. The rate of effective hemostasis was similar between the 4F-PCC and AA groups (66.7% vs 75%, p = 0.62). There were no statistically significant differences between the groups for secondary outcomes, including 28-day mortality (40.4% vs 39.1%, p = 0.92) and thrombotic complications within 28 days of reversal (17.0% vs 21.7%, p = 0.63). In patients who experienced an ICH while taking apixaban or rivaroxaban, 4F-PCC and AA were found to have similar rates of excellent or good hemostatic efficacy.
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Affiliation(s)
- Michelle Lipski
- Department of Pharmacy, University of Pittsburgh Medical Center Hamot, Erie, PA, 16506, USA.
| | - Stacy Pasciolla
- Department of Pharmacy, Philadelphia College of Pharmacy, Saint Joseph's University, Philadelphia, PA, USA.,Department of Pharmacy, Cooper University Health Care, Camden, NJ, USA
| | - Kevin Wojcik
- Department of Neurosurgery, Philadelphia College of Osteopathic Medicine, Philadelphia, PA, USA.,Department of Neurosurgery, Perelman School of Medicine at the Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Brian Jankowitz
- Department of Neurosurgery, Perelman School of Medicine at the Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Lauren A Igneri
- Department of Pharmacy, Cooper University Health Care, Camden, NJ, USA
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11
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Go AS, Leong TK, Sung SH, Wei R, Harrison TN, Gupta N, Baker N, Goldstein B, Ataher Q, Solomon MD, Reynolds K. Thromboembolism after treatment with 4-factor prothrombin complex concentrate or plasma for warfarin-related bleeding. J Thromb Thrombolysis 2022; 54:470-479. [PMID: 35984591 PMCID: PMC9553785 DOI: 10.1007/s11239-022-02695-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/06/2022] [Indexed: 11/26/2022]
Abstract
Limited data exist in large, representative populations about whether the risk of thromboembolic events varies after receiving four-factor human prothrombin complex concentrate (4F-PCC) versus treatment with human plasma for urgent reversal of oral vitamin K antagonist therapy. We conducted a multicenter observational study to compare the 45-day risk of thromboembolic events in adults with warfarin-associated major bleeding after treatment with 4F-PCC (Kcentra®) or plasma. Hospitalized patients in two large integrated healthcare delivery systems who received 4F-PCC or plasma for reversal of warfarin due to major bleeding from January 1, 2008 to March 31, 2020 were identified and were matched 1:1 on potential confounders and a high-dimensional propensity score. Arterial and venous thromboembolic events were identified up to 45 days after receiving 4F-PCC or plasma from electronic health records and adjudicated by physician review. Among 1119 patients receiving 4F-PCC and a matched historical cohort of 1119 patients receiving plasma without a recent history of thromboembolism, mean (SD) age was 76.7 (10.5) years, 45.6% were women, and 9.4% Black, 14.6% Asian/Pacific Islander, and 15.7% Hispanic. The 45-day risk of thromboembolic events was 3.4% in those receiving 4F-PCC and 4.1% in those receiving plasma (P = 0.26; adjusted hazard ratio 0.76; 95% confidence interval 0.49-1.16). The adjusted risk of all-cause death at 45 days post-treatment was lower in those receiving 4F-PCC compared with plasma. Among a large, ethnically diverse cohort of adults treated for reversal of warfarin-associated bleeding, receipt of 4F-PCC was not associated with an excess risk of thromboembolic events at 45 days compared with plasma therapy.
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Affiliation(s)
- Alan S Go
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA, 94612, USA.
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, USA.
- Departments of Epidemiology, Biostatistics and Medicine, University of California, San Francisco, CA, USA.
- Department of Medicine, Stanford University, Palo Alto, CA, USA.
| | - Thomas K Leong
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA, 94612, USA
| | - Sue Hee Sung
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA, 94612, USA
| | - Rong Wei
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Teresa N Harrison
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Nigel Gupta
- Department of Cardiac Electrophysiology, Southern CA Permanente Medical Group, Los Angeles, CA, USA
| | - Nicole Baker
- Clinical Epidemiology, CSL Behring, King of Prussia, PA, USA
| | - Brahm Goldstein
- Clinical Epidemiology, CSL Behring, King of Prussia, PA, USA
| | - Quazi Ataher
- Clinical Epidemiology, CSL Behring, King of Prussia, PA, USA
| | - Matthew D Solomon
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA, 94612, USA
- Department of Cardiology, Kaiser Permanente Oakland Medical Center, Oakland, CA, USA
| | - Kristi Reynolds
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, USA
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
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Pruthi P, Culliver C, Emel H, Georghie S, Benson MJ, Matalanis G, Yanase F, Bellomo R. Immediate Higher-Dose Prothrombin Complex Concentrate Without Fresh Frozen Plasma or Fibrinogen Concentrate for Significant Coagulopathic Cardiac Surgical Field Bleeding. Heart Lung Circ 2022:S1443-9506(22)00969-6. [PMID: 35843859 DOI: 10.1016/j.hlc.2022.05.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 05/23/2022] [Accepted: 05/26/2022] [Indexed: 11/20/2022]
Abstract
BACKGROUND Treatment of significant coagulopathic cardiac surgical field bleeding with immediate higher-dose prothrombin complex concentrate (PCC) without fresh frozen plasma (FFP) or fibrinogen concentrate is unexplored. AIMS To study characteristics, chest drainage, and clinical outcomes of patients with significant coagulopathic surgical field bleeding treated with immediate higher-dose (defined at >15 IU/kg based on factor IX) PCC without FFP or fibrinogen concentrate. METHODS We screened sequential cardiac surgery patients. We reviewed electronic blood bank data, Australian Society of Cardiothoracic Surgery database information and anaesthetic, intensive care unit (ICU), ward and radiological charts and electronic data. We identified patients deemed by the operating surgeon to require treatment for significant coagulopathic surgical field bleeding who underwent immediate higher-dose PCC without FFP or fibrinogen concentrate. RESULTS Among 168 patients, we identified 30 who underwent immediate higher-dose PCC without FFP or fibrinogen concentrate. Median age was 68 years, 23 were male, 17 underwent coronary artery bypass surgery and three underwent complex surgery (David procedure, redo mitral valve surgery, and redo thoraco-abdominal aneurysm repair). Median dose of PCC was 2,500 IU. In addition, 27% underwent platelets and one underwent cryoprecipitate. Chest drainage at 24 hours was 505 ml. Survival to hospital discharge was 100%. There were no cases of pulmonary embolism, stroke, or other thrombotic events. Stage 1 AKI occurred in one patient. CONCLUSION In a pilot cohort of patients with significant coagulopathic surgical field bleeding, immediate higher-dose PCC without FFP or fibrinogen concentrate was feasible and had an acceptable efficacy and safety profile, which justifies future controlled studies.
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Cooksey GE, Hamilton LA, McMillen JC, Griffard JH, Rowe AS. Impact of Factor Xa Inhibitor Reversal with Prothrombin Complex Concentrate in Patients with Traumatic Brain Injuries. Neurocrit Care 2022; 37:471-478. [PMID: 35624388 DOI: 10.1007/s12028-022-01521-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 04/18/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Anticoagulant use prior to trauma has been associated with increased incidence of traumatic brain injury (TBI), intracranial hemorrhage (ICH) progression, and mortality. Prothrombin complex concentrates (PCCs) are commonly used as off-label treatments for factor Xa inhibitor-associated life-threatening hemorrhage. At this time, there is no consensus regarding appropriate indication, target dose, or outcomes of PCC administration in patients presenting with traumatic ICH. This study seeks to evaluate the impact of reversal with PCC on hemorrhage progression and outcomes in patients with TBI on preinjury factor Xa inhibitors. METHODS This single-center retrospective cohort study included patients ≥ 18 years presenting with an acute TBI of any severity on apixaban or rivaroxaban from September 1, 2016, to September 1, 2019. Patients were grouped on the basis of receipt of PCCs for reversal (i.e., reversal or no reversal). Exclusion criteria included spontaneous ICH or known coagulopathy. Propensity score matching was conducted with the following variables: age, Abbreviated Injury Scale (head) score, and Charlson Comorbidity Index score. The primary outcome was hemorrhage stability within 48 h. Secondary outcomes included degree of hemorrhage progression, in-hospital mortality, discharge disposition, and incidence of thromboembolic events. RESULTS Of the 115 patients meeting inclusion criteria, 84 were included in the propensity score matched data set. Baseline characteristics, comorbidities, and TBI severity were similar. The majority of patients in the reversal group (35 [83.3%]) and the no reversal (NR) group (40 [95.2%]) experienced a mild TBI (admission Glasgow Coma Scale score of 14 to 15). In the reversal group, patients received 34.3 units/kg activated PCC, 30.5 units/kg four-factor PCC, or 54.9 units/kg four-factor PCC and activated PCC on average. There was no difference observed in the incidence of hemorrhage progression (10.8% NR vs. 15.0% reversal; p = 0.739) or in median change in ICH volume (0 mL NR vs. 1 mL reversal; p = 0.2199) between groups. Additionally, reversal did not affect in-hospital mortality (3 [7.1%] NR vs. 4 [9.5%] reversal; p > 0.999). One patient in the reversal group developed a deep vein thrombosis (DVT) during the hospitalization; however, this did not result in a statistically significant difference in the occurrence of DVT (p > 0.999). CONCLUSIONS This study demonstrated that PCC used for the treatment of factor Xa inhibitor-associated ICH related to mild TBI did not significantly impact the incidence or degree of hemorrhage progression, and PCC treatment did not result in increased thromboembolic events.
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Affiliation(s)
- Grace E Cooksey
- University of Tennessee Medical Center, 1924 Alcoa Highway, Box 117, Knoxville, TN, 37938, USA
- Atrium Health Wake Forest Baptist, Winston Salem, NC, USA
| | - Leslie A Hamilton
- University of Tennessee Medical Center, 1924 Alcoa Highway, Box 117, Knoxville, TN, 37938, USA
- University of Tennessee Health Science Center College of Pharmacy, Knoxville, TN, USA
| | - James C McMillen
- University of Tennessee Medical Center, 1924 Alcoa Highway, Box 117, Knoxville, TN, 37938, USA
| | - Jared H Griffard
- University of Tennessee Graduate School of Medicine, Knoxville, TN, USA
| | - A Shaun Rowe
- University of Tennessee Medical Center, 1924 Alcoa Highway, Box 117, Knoxville, TN, 37938, USA.
- University of Tennessee Health Science Center College of Pharmacy, Knoxville, TN, USA.
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14
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Bradshaw PG, Keegan S, Foertsch M, Yang GL, Ngwenya LB, Srinivasan V. Andexanet alfa after 4-factor PCC administration for intracranial hemorrhage: a case series. J Thromb Thrombolysis 2022; 54:295-300. [PMID: 35507109 DOI: 10.1007/s11239-022-02658-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/06/2022] [Indexed: 10/18/2022]
Abstract
The ongoing controversy regarding optimal reversal agent for factor Xa-inhibitors is mainly due to lack of comparative data of andexanet alfa (AA) to 4-factor prothrombin complex concentrate (4F-PCC), institutional formulary restrictions, and navigation of clinical scenarios involving patients clinically worsen despite initial reversal efforts. The combination use of 4F-PCC and AA has not been evaluated in clinical trials and the outcomes of such patients with FXA-inhibitor associated intracranial hemorrhage (ICH) are unknown. A total of five patients, including four outside hospital transfers, received 4F-PCC prior to AA for FXa-inhibitor associated ICH (n = 3 apixaban, n = 2 rivaroxaban; n = 4 ICH, n = 1 TBI). The doses of 4F-PCC ranged from 25 to 60 units/kg and were administered within a range of 1.5-4.2 h prior to AA. One patient required surgical intervention with craniotomy and three patients underwent external ventricular drain placement. Two of the five patients developed an ischemic or thromboembolic complication within one week from 4F-PCC and AA administration. This case series discusses multiple unique patient cases in which 4F-PCC and AA were both administered for FXa-inhibitor associated ICH. The results highlight the potentially increased thrombotic risk associated with combination use. Ongoing post-marketing data collection of real patient case scenarios are essential to the establishment of consensus guidelines on how to prioritize initial reversal efforts and manage these patients during the course of their bleed.
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Affiliation(s)
- Paige Garber Bradshaw
- Department of Pharmacy Services, University of Cincinnati Medical Center, Cincinnati, OH, USA. .,University of Cincinnati James L. Winkle College of Pharmacy, Cincinnati, OH, USA.
| | - Shaun Keegan
- Department of Pharmacy Services, University of Cincinnati Medical Center, Cincinnati, OH, USA.,University of Cincinnati James L. Winkle College of Pharmacy, Cincinnati, OH, USA
| | - Madeline Foertsch
- Department of Pharmacy Services, University of Cincinnati Medical Center, Cincinnati, OH, USA.,University of Cincinnati James L. Winkle College of Pharmacy, Cincinnati, OH, USA
| | - George L Yang
- University of Cincinnati Gardner Neuroscience Institute, Cincinnati, OH, USA.,Department of Neurosurgery, University of Cincinnati, Cincinnati, OH, USA
| | - Laura B Ngwenya
- University of Cincinnati Gardner Neuroscience Institute, Cincinnati, OH, USA.,Department of Neurosurgery, University of Cincinnati, Cincinnati, OH, USA
| | - Vasisht Srinivasan
- Department of Emergency Medicine, University of Washington School of Medicine, Seattle, USA
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15
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Josef AP, Garcia NM. Systemic Anticoagulation and Reversal. Surg Clin North Am 2022; 102:53-63. [PMID: 34800389 DOI: 10.1016/j.suc.2021.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
An increasing number of patients are on anticoagulation for a variety of indications. Patients on anticoagulation who present to the hospital with life-threatening hemorrhage, whether trauma related or not, must be assessed for the reversal of anticoagulation. Identification of the type of anticoagulation, the timing of the most recent usage of anticoagulation, and the efficacy of the anticoagulation all have an impact on whether reversal agents should be used. There are a variety of reversal agents, both nonspecific and specific, that could be used for reversal; however, not all reversal agents work for all anticoagulation medication. As more anticoagulation medications are used and indications expand, providers must be aware of the reversal agents available and the efficacy and indications for these reversal agents.
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16
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Davis SD, Chauv S, Hickman AW, Collingridge DS, Kjerengtroen S, Fontaine GV. High-dose versus low-dose 4-factor prothrombin complex concentrate for factor Xa inhibitor reversal in intracranial hemorrhage. Thromb Res 2021; 208:112-116. [PMID: 34749042 DOI: 10.1016/j.thromres.2021.10.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 10/21/2021] [Accepted: 10/27/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND & PURPOSE 4-factor prothrombin complex concentrate (4FPCC) is used off-label for factor Xa (FXa) inhibitor-associated intracranial hemorrhage (ICH). Guideline recommendations provide various 4FPCC dosing regimens for FXa inhibitor reversal in this setting. We evaluated 4FPCC weight-based dosing and outcomes in FXa inhibitor-associated ICH. METHODS We conducted a multi-center, retrospective, cohort study of ICH patients between July 2017 and February 2020. Patients were greater than 18 years of age, received 4FPCC, and were taking apixaban, rivaroxaban, or edoxaban. Patients were separated into high- (≥35 units/kg) or low-dose (<35 units/kg) 4FPCC groups. The primary outcome was hemostasis achievement. Secondary outcomes included in-hospital mortality, intensive care unit and hospital length of stay, discharge disposition, and thrombotic events. Outcomes were evaluated with binary logistic regression. RESULTS Of 390 patients identified, 89 were included with 74 and 15 in the high- vs low-dose groups, respectively. Mean (SD) age was 76.6 (±10.8) years. Most were taking a FXa inhibitor for atrial fibrillation (76.4%) and apixaban was the most common FXa inhibitor (65.2%). Hemostasis achievement was greater in the high- vs low-dose group (89.2% vs 46.7%; OR 11.2; 95% CI 2.4-52.6, P = 0.002). Thrombotic events were 8.2% and 6.7% in the high vs low-dose groups, respectively (OR 0.8; 95% CI 0.08-8.2, P = 0.87). No statistically significant differences were found in secondary outcomes. CONCLUSION In patients with FXa inhibitor-associated ICH, high-dose 4FPCC was associated with increased odds of hemostasis achievement. There was no difference in thrombotic events.
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Affiliation(s)
- Spencer D Davis
- Department of Pharmacy, Intermountain Medical Center, Murray, UT 84107, United States of America.
| | - Stephanie Chauv
- Department of Pharmacy, Intermountain Medical Center, Murray, UT 84107, United States of America
| | - Abby W Hickman
- Department of Pharmacy, Intermountain Medical Center, Murray, UT 84107, United States of America
| | - Dave S Collingridge
- Office of Research, Intermountain Healthcare, Murray, UT 84107, United States of America
| | - Sara Kjerengtroen
- Department of Pharmacy, Intermountain Medical Center, Murray, UT 84107, United States of America; Nebraska Medicine, Omaha, NE 68105, United States of America
| | - Gabriel V Fontaine
- Department of Pharmacy, Intermountain Medical Center, Murray, UT 84107, United States of America
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Tanaka KA, Shettar S, Vandyck K, Shea SM, Abuelkasem E. Roles of Four-Factor Prothrombin Complex Concentrate in the Management of Critical Bleeding. Transfus Med Rev 2021; 35:96-103. [PMID: 34551881 DOI: 10.1016/j.tmrv.2021.06.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Accepted: 06/27/2021] [Indexed: 12/19/2022]
Abstract
Four-factor prothrombin complex concentrate (4F-PCC) is the term used to describe a pathogen-reduced, lyophilized concentrate that contains therapeutic amounts of at least 4 coagulation factors: Factor II (FII), Factor VII (FVII), Factor IX (FIX), and Factor X (FX). 4F-PCC has proven to be an effective hemostatic agent compared to plasma transfusion in several prospective randomized trials in acute warfarin reversal. In recent years, 4F-PCC has been used in various acquired coagulopathies including post-cardiopulmonary bypass bleeding, trauma-induced coagulopathy, coagulopathy in liver failure, and major bleeding due to anti-FXa (anti-Xa) inhibitors (eg, rivaroxaban and apixaban). As transfusion of frozen plasma (FP) has not been found efficacious in the above critical bleeding scenarios, there is increasing interest in expanding the use of 4F-PCC. However, efficacy, safety, and clinical implications of expanded use of 4F-PCC have not been fully elucidated. Prothrombin time and international normalized ratio are commonly used to assess dose effects of 4F-PCC. Prothrombin time/international normalized ratio are standardly use for warfarin titration, but they are not suited for real-time monitoring of complex coagulopathies. Optimal dosing of 4F-PCC outside of the current approved use for vitamin K antagonist reversal is yet to be determined. In this review, we will discuss the use of 4F-PCC in four critical bleeding settings: cardiac surgery, major trauma, end-stage liver disease, and oral anti-Xa reversal. We will discuss recent studies in each area to explore the dosing, efficacy, and safety of 4F-PCC.
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Affiliation(s)
- Kenichi A Tanaka
- Department of Anesthesiology, University of Oklahoma College of Medicine, Oklahoma City, OK, USA.
| | - Shashank Shettar
- Department of Anesthesiology, University of Oklahoma College of Medicine, Oklahoma City, OK, USA
| | - Kofi Vandyck
- Department of Anesthesiology, University of Oklahoma College of Medicine, Oklahoma City, OK, USA
| | - Susan M Shea
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Ezeldeen Abuelkasem
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA, USA
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18
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Bouzat P, Bosson JL, David JS, Riou B, Duranteau J, Payen JF. Four-factor prothrombin complex concentrate to reduce allogenic blood product transfusion in patients with major trauma, the PROCOAG trial: study protocol for a randomized multicenter double-blind superiority study. Trials 2021; 22:634. [PMID: 34530886 PMCID: PMC8444177 DOI: 10.1186/s13063-021-05524-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 08/09/2021] [Indexed: 02/08/2023] Open
Abstract
Background Optimal management of severe trauma patients with active hemorrhage relies on adequate initial resuscitation. Early administration of coagulation factors improves post-traumatic coagulation disorders, and four-factor prothrombin complex concentrate (PCC) might be useful in this context. Our main hypothesis is that four-factor PCC in addition to a massive transfusion protocol decreases blood product consumption at day 1 in severe trauma patients with major bleeding. Methods This is a prospective, randomized, multicenter, double-blind, parallel, controlled superiority trial. Eligible patients are trauma patients with major bleeding admitted to a French level-I trauma center. Patients randomized in the treatment arm receive 1 mL/kg (25 IU/ml of Factor IX/Kg) four-factor PCC within 1-h post-admission while patients randomized in the controlled group receive 1 mL/kg of saline solution 0.9% as a placebo. Treatments are given as soon as possible using syringe pumps (120 mL/h). The primary endpoint is the amount of blood products transfused in the first 24 h post-admission (including red blood cells, frozen fresh plasma, and platelets). The secondary endpoints are the amount of each blood product transfused in the first 24 h, time to achieve prothrombin time ratio < 1.5, time to hemostasis, number of thrombo-embolic events at 28 days, mortality at 24 h and 28 days, number of intensive care unit-free days, number of ventilator-free days, number of hospital-free days within the first 28 days, hospitalization status at day 28, Glasgow outcome scale extended for patients with brain lesions on initial cerebral imaging, and cost of each strategy at days 8 and 28. Inclusions have started in December 2017 and are expected to be complete by June 2021. Discussion If PCC reduces total blood consumption at day 1 after severe trauma, this therapy, in adjunction to a classic massive transfusion protocol, may be used empirically on admission in patients at risk of massive transfusion to enhance coagulation. Moreover, this treatment may decrease blood product-related complications and may improve clinical outcomes after post-traumatic hemorrhage. Trial registration ClinicalTrials.gov NCT03218722. Registered on July 14, 2017
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Affiliation(s)
- Pierre Bouzat
- Pôle Anesthésie-Réanimation, Centre Hospitalo-Universitaire Grenoble-Alpes, Grenoble, France.
| | - Jean-Luc Bosson
- Univ. Grenoble Alpes, CNRS, Public Health department CHU Grenoble Alpes, TIMC-IMAG, 38000, Grenoble, France
| | - Jean-Stéphane David
- Service d'Anesthésie Réanimation, Centre Hospitalo-Universitaire Lyon-Sud, Faculté de Médecine Lyon-Est, Université Claude Bernard Lyon 1, Lyon, France
| | - Bruno Riou
- Sorbonne Université, UMRS INSERM 116, IHU ICAN, et Service des urgences, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Jacques Duranteau
- Département d'Anesthésie-Réanimation, Hôpitaux Universitaires Paris Sud, Université Paris XI, Faculté de Médecine Paris-Sud, Le Kremlin-Bicêtre, France
| | - Jean-François Payen
- Pôle Anesthésie-Réanimation, Centre Hospitalo-Universitaire Grenoble-Alpes, Grenoble, France
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Dietrich SK, Mixon MA, Rech MA. Fixed-dose prothrombin complex concentrate for emergent warfarin reversal among patients with intracranial hemorrhage. Am J Emerg Med 2021; 49:326-330. [PMID: 34224954 DOI: 10.1016/j.ajem.2021.06.032] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 02/24/2021] [Accepted: 06/13/2021] [Indexed: 10/21/2022] Open
Abstract
INTRODUCTION Four-factor prothrombin complex concentrate (4PCC) is the preferred reversal agent for warfarin reversal, although the ideal dose is unknown. Fixed-dose 4PCC offers simplified dosing compared to standard-dosing algorithms with potentially lower risks of thromboembolic complications given lower doses are typically utilized. METHODS Retrospective, observational, multicentered, pre- post- study of patients who received 4PCC for warfarin reversal among four hospitals within the same regional health system. Standard-dose patients received variable doses ranging from 25 to 50 units/kg based on total body weight and initial INR and fixed-dose patients received 2000 units. The primary outcome was achievement of a target INR ≤ 1.4 on the first post-4PCC INR result. RESULTS After exclusions, 48 and 42 patients were analyzed in the standard-dose and fixed-dose groups, respectively. There was no difference in the ability to achieve a target INR of ≤1.4 (82.6% vs 81.5%, p = 0.14). Both groups received the same median dose of 2000 units, although fixed-dose patients actually received a higher weight-based dose than standard-dose patients (27 units/kg vs 24.5 units/kg). CONCLUSION A fixed-dose 4PCC regimen of 2000 units among patients with ICH was as effective as standard-dose 4PCC for INR reversal among patients with ICH. However, fixed-doses of 2000 units at times exceeded standard 4PCC doses which may be contradictory to the goals of fixed-dose 4PCC for warfarin reversal.
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Affiliation(s)
- Scott K Dietrich
- University of of Colorado Health- North, Department of Pharmacy, Fort Collins, CO, United States of America.
| | - Mark A Mixon
- University of of Colorado Health- North, Department of Pharmacy, Fort Collins, CO, United States of America
| | - Megan A Rech
- Loyola University Medical Center, Department of Pharmacy, United States of America; Department of Emergency Medicine, Stritch School of Medicine, Loyola University of Chicago, United States of America
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20
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Naeem Z, Allan S, Hernandez A, Galanakis DK, Singer AJ. Clinical utilization of four-factor prothrombin complex concentrate: a retrospective single center study. Clin Exp Emerg Med 2021; 8:75-81. [PMID: 34237811 PMCID: PMC8273669 DOI: 10.15441/ceem.20.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 06/16/2020] [Accepted: 06/19/2020] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE Four-factor prothrombin complex concentrate (4F-PCC) was approved by the US Food and Drug Administration in 2013 for management of severely bleeding patients on warfarin therapy. We describe use of 4F-PCC at a large, suburban academic center. METHODS We retrospectively reviewed all patients receiving 4F-PCC from its introduction through 2016 at a large level 1 trauma center. Clinical and demographic data were obtained, including indications for anticoagulation and antiplatelet agents, comorbidities, concomitant medications, etiology and site of bleeding, as well as disposition, length of stay, mortality, and thrombotic events. RESULTS One hundred eighty-four patients received 4F-PCC. Mean age was 72 years; 40.8% were female. Indications for 4F-PCC administration included: active bleeding (74%), reversal prior to a procedure (14%), and elevated international normalized ratio (12%). Warfarin was the most common concomitant medication (71.1%). Most patients were receiving anticoagulation for atrial fibrillation (63%). Concomitant treatments for bleeding included vitamin K (58.2%), packed red blood cells (50%), fresh frozen plasma (38%), and platelets (26.1%), amongst others. Median length of hospital stay was 8.4 days. Nine patients (4.9%) developed thrombosis within 90 days of 4F-PCC. Mortality was 24.5%, with notably higher rates amongst those who received 4F-PCC for off-label indications (19.1% on-label mortality vs. 37.7% off-label mortality on chi-square analysis, P=0.01). CONCLUSION This study demonstrates that 4F-PCC is being utilized for indications other than the reversal of warfarin-induced coagulopathy. Further investigation is warranted to determine the efficacy and safety of 4F-PCC for these potential indications.
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Affiliation(s)
- Zaina Naeem
- Department of Emergency Medicine, Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, USA
| | - Salsabeel Allan
- Department of Emergency Medicine, Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, USA
| | - Aneury Hernandez
- Department of Emergency Medicine, Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, USA
| | - Dennis K Galanakis
- Department of Pathology, Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, USA
| | - Adam J. Singer
- Department of Emergency Medicine, Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, USA
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Koller T, Kinast N, Castellanos AG, Garcia SP, Iglesias PP, Vintro XL, Arranz JM, Seto NV, García MVM, Moreno-Castaño AB, Aznar-Salatti J, Albaladejo GE, Diaz-Ricart M. Normalization of blood clotting characteristics using prothrombin complex concentrate, fibrinogen and FXIII in an albumin based fluid: experimental studies in thromboelastometry. Scand J Trauma Resusc Emerg Med 2021; 29:57. [PMID: 33836790 PMCID: PMC8035752 DOI: 10.1186/s13049-021-00867-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Accepted: 03/15/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Colloid fluids supplemented with adequate combinations of coagulation factor concentrates with the capability to restore coagulation could be a desirable future treatment component in massive transfusion. METHODS Starting from a coagulation factor and blood cell-free albumin solution we added Prothrombin Complex Concentrate, Fibrinogen Concentrate and Factor XIII in different combinations and concentrations to analyze their properties to restore thromboelastometry parameters without the use of plasma. Further analysis under the presence of platelets was performed for comparability to whole blood conditions. RESULTS Albumin solutions enriched with Fibrinogen Concentrate, Factor XIII and Prothrombin Complex Concentrate at optimized concentrations show restoring coagulation potential. Prothrombin Complex Concentrate showed sufficient thrombin formation for inducing fibrinogen polymerization. The combination of Prothrombin Complex Concentrate and Fibrinogen Concentrate led to the formation of a stable in vitro fibrin clot. Fibrinogen and Factor XIII showed excellent capacity to improve fibrin clot firmness expressed as Amplitude at 10 min and Maximal Clot Firmness. Fibrinogen alone, or in combination with Factor XIII, was able to restore normal Amplitude at 10 min and Maximal Clot Firmness values. In the presence of platelets, the thromboelastometry surrogate parameter for thrombin generation (Clotting Time) improves and normalizes when compared to whole blood. CONCLUSIONS Combinations of coagulation factor concentrates suspended in albumin solutions can restore thromboelastometry parameters in the absence of plasma. This kind of artificial colloid fluids with coagulation-restoring characteristics might offer new treatment alternatives for massive transfusion. TRIAL REGISTRATION Study registered at the institutional ethic committee "Institut de Recerca, Hospital Santa Creu i Sant Pau, with protocol number IIBSP-CFC-2013-165.
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Affiliation(s)
- Tobias Koller
- Hospital de la Santa Creu i San Pau, Universidad Autonoma de Barcelona, Departamento de Cirugía, Carrer de Sant Quintí, 89, 08041, Barcelona, Spain.
| | - Nadia Kinast
- Consorci Sanitari Alt Penedés-Garraf, Carrer de l'Espirall, s/n, Vilafranca del Penedés, Spain
| | | | - Sergio Perez Garcia
- Hospital de la Santa Creu i San Pau, Universidad Autonoma de Barcelona, Departamento de Cirugía, Carrer de Sant Quintí, 89, 08041, Barcelona, Spain
| | - Pilar Paniagua Iglesias
- Hospital de la Santa Creu i San Pau, Universidad Autonoma de Barcelona, Departamento de Cirugía, Carrer de Sant Quintí, 89, 08041, Barcelona, Spain
| | - Xavi León Vintro
- Hospital de la Santa Creu i San Pau, Universidad Autonoma de Barcelona, Departamento de Cirugía, Carrer de Sant Quintí, 89, 08041, Barcelona, Spain
| | - Jose Mateo Arranz
- Hospital de la Santa Creu i San Pau, Universidad Autonoma de Barcelona, Departamento de Cirugía, Carrer de Sant Quintí, 89, 08041, Barcelona, Spain
| | - Noelia Vilalta Seto
- Hospital de la Santa Creu i San Pau, Universidad Autonoma de Barcelona, Departamento de Cirugía, Carrer de Sant Quintí, 89, 08041, Barcelona, Spain
| | - Ma Victòria Moral García
- Hospital de la Santa Creu i San Pau, Universidad Autonoma de Barcelona, Departamento de Cirugía, Carrer de Sant Quintí, 89, 08041, Barcelona, Spain
| | - Ana Belén Moreno-Castaño
- Hematopathology, Pathology Department, CDB, Hospital Clinic, IDIBAPS, University of Barcelona, Barcelona, Spain
| | | | - Gines Escolar Albaladejo
- Hematopathology, Pathology Department, CDB, Hospital Clinic, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Maribel Diaz-Ricart
- Hematopathology, Pathology Department, CDB, Hospital Clinic, IDIBAPS, University of Barcelona, Barcelona, Spain
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22
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Varnes BE, Singh V, May CC. Management of warfarin-associated intracerebral hemorrhage before and after implementation of an order set and prospective pharmacist order verification. J Thromb Thrombolysis 2021; 52:239-247. [PMID: 33661477 DOI: 10.1007/s11239-021-02404-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/16/2021] [Indexed: 01/07/2023]
Abstract
Management of warfarin-associated intracerebral hemorrhage (ICH) necessitates rapid reversal of anticoagulation. Guideline-based management of warfarin-associated ICH includes timely administration of prothrombin complex concentrate (PCC) and intravenous (IV) vitamin K. In 2017, our hospital implemented an order set for warfarin reversal to facilitate computerized provider order entry (CPOE), and the pharmacy department began prospective verification and dispensing of all PCC orders for anticoagulant reversal. We sought to compare the proportion of patients who received timely, guideline-based therapy for warfarin-associated ICH before and after these changes. We conducted a single-center, retrospective cohort study of all warfarin-associated ICH patients who had an order for PCC. A total of 66 patients were included; 32 patients (pre-intervention cohort) were evaluated in the 2 year period prior to the process improvement changes, while 34 patients (post-intervention cohort) were evaluated in the 2 year period following these changes. Baseline characteristics were similar between groups. The proportion of patients receiving timely guideline-based therapy was significantly higher in the post-intervention cohort compared to the pre-intervention cohort (76.5% vs 34.4%, p < 0.001), primarily driven by increased ordering of vitamin K 10 mg IV in conjunction with PCC in the post-intervention cohort. Our results indicate that implementation of an order set to assist with CPOE, in addition to prospective pharmacist verification of PCC orders, leads to increased adherence to guideline-based management of warfarin-associated ICH.
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Affiliation(s)
- Beth E Varnes
- Department of Pharmacy, UAB Hospital, 619 19th Street South, Birmingham, AL, 35249, USA.
| | - Vinodkumar Singh
- Division of Critical Care Medicine, Department of Anesthesiology and Perioperative Medicine, UAB Hospital, 619 S, 19th Street South, Birmingham, AL, 35249, USA
| | - Casey C May
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Doan Hall Room 368 410 W, 10th Ave, Columbus, OH, 43210, USA
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23
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Kamihara Y, Kikuchi S, Wada A, Murakami J, Sugie N, Niimi H, Nakashima A, Sato T. [Successful preoperative replacement of prothrombin with prothrombin complex concentrate for Prothrombin Himi]. Rinsho Ketsueki 2021; 62:1412-1414. [PMID: 34615802 DOI: 10.11406/rinketsu.62.1412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Dysprothrombinemia is the rarest inherited bleeding disorder that is characterized by a decrease in the prothrombin activity, but normal antigen levels. In this study, we report the case of a compound heterozygote of two mutations in prothrombin; Met337Thr and Arg388His, which has previously been identified as "Prothrombin Himi." A systemic blood coagulation evaluation revealed a prolonged prothrombin time (39%) and activated partial thromboplastin (64.4 sec), with an isolated severe decrease in the prothrombin activity (8.6%). Preoperative replacement of prothrombin with prothrombin complex concentrate, PPSB-HT "Nichiyaku," successfully prevented abnormal postoperative bleeding after laparoscopic hysterectomy for cervical cancer. This is the second reported case of Prothrombin Himi.
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Affiliation(s)
| | | | - Akinori Wada
- Department of Hematology, Toyama University Hospital
| | - Jun Murakami
- Division of Clinical Laboratory and Blood Center, Toyama University Hospital
| | - Nana Sugie
- Division of Clinical Laboratory and Blood Center, Toyama University Hospital
| | - Hideki Niimi
- Division of Clinical Laboratory and Blood Center, Toyama University Hospital
| | | | - Tsutomu Sato
- Department of Hematology, Toyama University Hospital
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24
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Lumas SG, Hsiang W, Becher RD, Maung AA, Davis KA, Schuster KM. Choosing the Best Approach to Warfarin Reversal After Traumatic Intracranial Hemorrhage. J Surg Res 2020; 260:369-376. [PMID: 33388533 DOI: 10.1016/j.jss.2020.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Revised: 11/17/2020] [Accepted: 12/08/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Patients on warfarin with traumatic intracranial hemorrhage often have the warfarin effects pharmacologically reversed. We compared outcomes among patients who received 4-factor prothrombin complex concentrate (PCC), fresh frozen plasma (FFP), or no reversal to assess the real-world impact of PCC on elderly patients with traumatic intracranial hemorrhage (ICH). MATERIALS AND METHODS This was a retrospective analysis of 150 patients on preinjury warfarin. Data were manually abstracted from the electronic medical record of an academic level 1 trauma center for patients admitted between January 2013 and December 2018. Outcomes were ICH progression on follow-up computed tomography scan, mortality, need for surgical intervention, and trends in the use of reversal agents. RESULTS Of 150 patients eligible for analysis, 41 received FFP, 60 PCC, and 49 were not reversed. On multivariable analysis, patients not reversed [OR 0.25 95% CI (0.31-0.85)] and women [OR 0.38 95% CI (0.17-0.88)] were less likely to experience progression of their initial bleed on follow-up computed tomography while subdural hemorrhage increased the risk [OR 3.69 95% CI (1.27-10.73)]. There was no difference between groups in terms of mortality or need for surgery. Over time use of reversal with PCC increased while use of FFP and not reversing warfarin declined (P < 0.001). CONCLUSIONS Male gender and using a reversal agent were associated with progression of ICH. Choice of reversal did not impact the need for surgery, hospital length of stay, or mortality. Some ICH patients may not require warfarin reversal and may bias studies, especially retrospective studies of warfarin reversal.
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Affiliation(s)
- Shunella G Lumas
- Division of General Surgery, Department of Surgery, Trauma, and Surgical Critical Care, Yale School of Medicine, New Haven, Connecticut
| | - Walter Hsiang
- Division of General Surgery, Department of Surgery, Trauma, and Surgical Critical Care, Yale School of Medicine, New Haven, Connecticut
| | - Robert D Becher
- Division of General Surgery, Department of Surgery, Trauma, and Surgical Critical Care, Yale School of Medicine, New Haven, Connecticut
| | - Adrian A Maung
- Division of General Surgery, Department of Surgery, Trauma, and Surgical Critical Care, Yale School of Medicine, New Haven, Connecticut
| | - Kimberly A Davis
- Division of General Surgery, Department of Surgery, Trauma, and Surgical Critical Care, Yale School of Medicine, New Haven, Connecticut
| | - Kevin M Schuster
- Division of General Surgery, Department of Surgery, Trauma, and Surgical Critical Care, Yale School of Medicine, New Haven, Connecticut.
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25
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Osama M, Syed SH, Nasir HMSA, Zaidi SR. Four-Factor Prothrombin Complex Concentrate: An Indispensable Adjunct in Coagulopathy of Trauma Management - A Comparative Review of the Literature over 2 Decades. Eur Surg Res 2020; 61:51-61. [PMID: 32966972 DOI: 10.1159/000509876] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 07/01/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Damage control resuscitation forms the cornerstone of management in trauma surgery. Several blood products have been widely used for preoperative transfusions prior to emergency surgeries and for hemorrhage control in trauma. Prothrombin complex concentrate (PCC) is now being introduced as an essential component of damage control resuscitation. SUMMARY We did a comparative descriptive analysis of several single and multi-institutional clinical trials and retrospective cohort studies. The primary focus of these studies was a comparison between PCC and other transfusion modalities including recombinant factor VIIa, fresh-frozen plasma, and fibrinogen based on several vital parameters. The parameters included rapid international normalized ratio reversal, hospital length of stay, cost-effectiveness, mortality rate, and rate of thromboembolic complications. KEY POINTS Although still awaiting its approval from the FDA for use in traumatic coagulopathy, 4-factor PCC has shown far more convincing results in contrast to former transfusion modalities, even 3-factor PCC. However, more prospective extensive clinical trials on national levels are needed to compare its effectiveness to 3-factor PCC and gather promising recognition in the trauma care fraternity.
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Affiliation(s)
- Muhammad Osama
- Department of Surgery, Dow University of Health Sciences, Karachi, Pakistan
| | - Sohaib Hasan Syed
- Department of Internal Medicine, St. Mary Mercy Hospital, Livonia, Michigan, USA,
| | | | - Syeda Ramsha Zaidi
- Department of Internal Medicine, St. Mary Mercy Hospital, Livonia, Michigan, USA
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26
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Korobey MJ, Sadaka F, Javed M, Moynihan M, Alsaei A. Efficacy of 4-Factor Prothrombin Complex Concentrates in Factor Xa Inhibitor-Associated Intracranial Bleeding. Neurocrit Care 2020; 34:112-120. [PMID: 32430804 DOI: 10.1007/s12028-020-00968-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND/OBJECTIVE Intracranial bleeding (ICB) is a feared complication of systemic anticoagulation. Factor Xa inhibitors (FXaI) are used frequently due to their improved safety profile and predictable kinetics. Andexanet alfa was recently approved for emergent reversal of FXaI agents but was not compared formally to 4-Factor Prothrombin Complex Concentrates (4FPCC) which are the current standard of care in many centers. The objective of this study is to formally evaluate the hemostatic efficacy of 4FPCC in patients with FXaI-associated ICB. METHODS We performed a retrospective cohort study of patients receiving 4FPCC for the reversal of a FXaI in the setting of acute ICB. Hemostatic efficacy was adjudicated via evaluation of post-4FPCC CT scan using the criteria closely mirroring those outlined in Annexa-4 (excellent < 20% expansion, good > 20% but ≤ 35% expansion, poor > 35% expansion). Each image was reviewed by two neurointensivist attendings for grading. Mortality was assessed until date of discharge. Charts were screened for thrombotic events out to 30 days post-4FPCC administration. RESULTS A total of 59 patients were included in the final analysis. The mean age in years was 78.5 ± 10.9 and 56% were male. Apixaban was the most common FXaI prescribed at the time of presentation (67.8%). Most patients were on FXaI therapy for stroke prevention in the setting of atrial fibrillation (81.3%). Median Glasgow Coma Scale at presentation was 15(IQR 12-15), with the most frequently presenting ICB type being intracerebral hemorrhage (52.5%). The mean dose of 4FPCC prescribed was 46.6 (± 8.2) units/kg. Of those receiving 4FPCC for FXaI ICB, 88% were graded as having an excellent or good hemostatic outcome with excellent interrater reliability. Survival was high at 89.8%, and thrombotic events were seen in seven patients (11.9%). CONCLUSION 4FPCC appears to be an effective and safe option for FXaI-associated ICB with outcomes comparable to andexanet alfa. A formal prospective evaluation of this strategy versus andexanet alpha including cost analysis is warranted.
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Affiliation(s)
- Matthew J Korobey
- Department of Critical Care Medicine, Mercy Hospital St. Louis, 615 S. New Ballas Road, St. Louis, MO, 63303, USA.
| | - Farid Sadaka
- Department of Critical Care Medicine, Mercy Hospital St. Louis, 615 S. New Ballas Road, St. Louis, MO, 63303, USA
| | - Muhammad Javed
- Department of Critical Care Medicine, Mercy Hospital St. Louis, 615 S. New Ballas Road, St. Louis, MO, 63303, USA
| | | | - Ahmed Alsaei
- Department of Critical Care Medicine, Mercy Hospital St. Louis, 615 S. New Ballas Road, St. Louis, MO, 63303, USA
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27
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Imanaka S, Kuwabara T, Ikeda H, Miyake Y, Enomoto H, Sakamoto T, Yasuno N. Emergency intensive care unit pharmacist's intervention may reduce time to four-factor prothrombin complex concentrate administration: a retrospective study. J Pharm Health Care Sci 2020; 6:7. [PMID: 32266076 PMCID: PMC7118855 DOI: 10.1186/s40780-020-00161-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Accepted: 03/03/2020] [Indexed: 11/24/2022] Open
Abstract
Background Four-factor prothrombin complex concentrate (4F-PCC) must be administered as soon as possible, and in our emergency intensive care unit (EICU), pharmacists are available on weekdays for consultation on expediting 4F-PCC administration. Although recent reports have described a reduction in time to 4F-PCC administration, few studies have addressed if this is because of EICU pharmacist’s intervention, and there are no such studies in Japan. Therefore, we aimed to examine whether EICU pharmacist’s intervention reduced time to 4F-PCC administration. Methods This single-center retrospective cohort study was conducted from December 2017 to May 2019. We enrolled patients who received 4F-PCC due to major bleeding or requirement of urgent surgical/invasive procedures (n = 10). Patients were divided into two groups, namely, the intervention group (n = 5), in which EICU pharmacists consulted on weekdays, and the nonintervention group (n = 5), in which an intervention was not possible because of the absence of the EICU pharmacist. Results The median time from patient presentation to the EICU to 4F-PCC administration (103 min vs. 111 min, p = 0.4) was similar between the two groups; however, the median time from 4F-PCC prescription ordering to administration was significantly shorter in the intervention group than in the nonintervention group (21 min vs. 60 min, p = 0.02). Conclusions EICU pharmacist’s intervention improves the process from 4F-PCC prescription to administration and can reduce time to 4F-PCC administration.
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Affiliation(s)
- Shoichi Imanaka
- 1Pharmaceutical Department, Teikyo University School of Medicine Hospital, 2-11-1 Kaga, Itabashi-Ku, Tokyo, 173-8605 Japan
| | - Tatsuro Kuwabara
- 1Pharmaceutical Department, Teikyo University School of Medicine Hospital, 2-11-1 Kaga, Itabashi-Ku, Tokyo, 173-8605 Japan
| | - Hiroto Ikeda
- 2Department of Emergency Medicine, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-Ku, Tokyo, 173-8605 Japan
| | - Yasufumi Miyake
- 2Department of Emergency Medicine, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-Ku, Tokyo, 173-8605 Japan
| | - Hiromi Enomoto
- 1Pharmaceutical Department, Teikyo University School of Medicine Hospital, 2-11-1 Kaga, Itabashi-Ku, Tokyo, 173-8605 Japan
| | - Tetsuya Sakamoto
- 2Department of Emergency Medicine, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-Ku, Tokyo, 173-8605 Japan
| | - Nobuhiro Yasuno
- 1Pharmaceutical Department, Teikyo University School of Medicine Hospital, 2-11-1 Kaga, Itabashi-Ku, Tokyo, 173-8605 Japan.,3Laboratory of Hospital Pharmacy Sciences, Faculty of Pharma Science, Teikyo University, 2-11-1 Kaga, Itabashi-Ku, Tokyo, 173-8605 Japan
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28
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Choudhury M, Chalil S, Abozguia K. Life-threatening pericardial bleed complicating atrial fibrillation ablation associated with edoxaban therapy successfully managed with prothrombin complex concentrate. HeartRhythm Case Rep 2020; 6:163-165. [PMID: 32181137 PMCID: PMC7064795 DOI: 10.1016/j.hrcr.2019.12.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Moinuddin Choudhury
- Lancashire Cardiac Centre, Blackpool Victoria Hospital, Blackpool, United Kingdom
| | - Shajil Chalil
- Lancashire Cardiac Centre, Blackpool Victoria Hospital, Blackpool, United Kingdom
| | - Khalid Abozguia
- Lancashire Cardiac Centre, Blackpool Victoria Hospital, Blackpool, United Kingdom
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29
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Marrinan E, Chen L, Werring D, Turner D. Reducing delays to administration of prothrombin complex concentrate in patients with vitamin K antagonist-related intracerebral haemorrhage. Br J Hosp Med (Lond) 2020; 81:1-6. [PMID: 32097070 DOI: 10.12968/hmed.2020.0007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND/AIMS Four-factor prothrombin complex concentrate is the first-line treatment in vitamin K antagonist-related intracerebral haemorrhage. Early administration is associated with improved patient outcomes. A quality improvement project investigated delays in prothrombin complex concentrate administration in vitamin K antagonist-related intracerebral haemorrhage in order to reduce the time from computed tomography scan confirming intracerebral haemorrhage to prothrombin complex concentrate administration (scan-to-needle time). METHOD Twenty patients were identified by retrospective audit over a 3-year period. The median scan-to-needle time for prothrombin complex concentrate was 156 minutes. Several points of delay were identified, including contacting both haematology and transfusion departments for prothrombin complex concentrate dosing and dispensing. Following this audit, interventions were brought in which included the introduction of a protocol with a prothrombin complex concentrate dosing algorithm, negating the need to contact haematology before administration. A dedicated supply of prothrombin complex concentrate was given to the stroke unit avoiding the need to contact the transfusion service. RESULTS A re-audit showed a 68% reduction in median scan-to-needle time from 156 minutes to 49 minutes. Prospective data collection is ongoing.
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Affiliation(s)
| | - Lucia Chen
- Hyper-acute Stroke Unit, University College London Hospital, London, UK
| | - David Werring
- Hyper-acute Stroke Unit, University College London Hospital, London, UK.,Acute Stroke and Brain Injury Unit, National Hospital for Neurology and Neurosurgery, London, UK
| | - David Turner
- Hyper-acute Stroke Unit, University College London Hospital, London, UK.,Acute Stroke and Brain Injury Unit, National Hospital for Neurology and Neurosurgery, London, UK
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30
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Green L, Roberts N, Cooper J, Field J, Gill R, Klein A, Agarwal S, Stanworth S, Johnston A, Monk V, O’Brien B. A pragmatic pilot phase II randomised controlled trial of prothrombin complex concentrates (PCC) versus fresh frozen plasma (FFP) in adult patients who are undergoing heart surgery (PROPHESY). Trials 2019; 20:684. [PMID: 31815658 PMCID: PMC6902595 DOI: 10.1186/s13063-019-3759-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 09/26/2019] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Fresh frozen plasma (FFP) is the accepted standard treatment for clotting factor replacement in bleeding patients during or immediately after cardiac surgery. In the United Kingdom prothrombin complex concentrate (PCC) is not licensed in this setting, although it is being used in Europe because it has a higher concentration of clotting factor levels, and it can be administered rapidly and in small volume, resulting in less volume overload during cardiac surgery. METHODS PROPHESY is a pragmatic, single-centre, open-label, randomised, controlled pilot trial that will assess whether it is feasible to perform a large trial in the future that will compare PCC versus FFP in patients who are bleeding (not on warfarin) and who require blood transfusion. Over a 15-month period, 50 patients will be randomised to PCC versus FFP if they develop active bleeding within 24 h of cardiac surgery and for whom the clinician has decided to administer FFP for treatment of bleeding. Standard laboratory and point-of-care assessments will be performed as per routine practice, and additional research blood samples will be taken at three time points to assess haemostasis. Subjects will be assessed daily up to hospital discharge or 30 days or death (whichever occurs first) and will be seen in follow-up for 90 days after surgery to assess for thromboembolic complications and hospital re-admission since discharge. Quality-of-life assessment will be performed pre-surgery and at 90 days post-surgery. We will also perform qualitative research with clinical experts and patients to explore the understanding of and experience with the interventions, as well as adherence to study procedures and protocol. DISCUSSION There have been no randomised controlled trials that have compared the safety and efficacy of FFP versus PCC in cardiac surgery patients who are bleeding. This pilot study will assess if individual components of a large trial are deliverable to assess the safety and efficacy of the two blood products in the future. TRIAL REGISTRATION EudraCT, 2018-003041-41; ClinicalTrials.gov, NCT03715348. Registered on 29 July 2018.
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Affiliation(s)
- Laura Green
- 0000 0001 2171 1133grid.4868.2Blizard Institute, Queen Mary University of London, NHS Blood and Transplant and Barts Health NHS Trust, 4 Newark Street, Whitechapel, London, E1 2AT UK
| | - Neil Roberts
- 0000 0000 9244 0345grid.416353.6St Bartholomew’s Hospital, West Smithfield, London, EC1A 7BE UK
| | - Jackie Cooper
- 0000 0001 2171 1133grid.4868.2Barts Cardiovascular Clinical Trials Unit (CVCTU), William Harvey Research Institute, Heart Centre, Barts and The London School of Medicine, Queen Mary University of London, Charterhouse Square, London, EC1M 6BQ UK
| | - Jane Field
- 0000 0001 2171 1133grid.4868.2Barts Cardiovascular Clinical Trials Unit (CVCTU), William Harvey Research Institute, Heart Centre, Barts and The London School of Medicine, Queen Mary University of London, Charterhouse Square, London, EC1M 6BQ UK
| | - Ravi Gill
- 0000000103590315grid.123047.3Southampton General Hospital, Tremona Road, Southampton, SO16 6YD UK
| | - Andrew Klein
- Papworth Hospitals NHS Foundation Trust, Papworth Everard, Cambridge, CB23 3RE UK
| | - Seema Agarwal
- 0000 0004 0641 2823grid.419319.7Manchester Royal Infirmary, Oxford Road, Manchester, M13 9WL UK
| | - Simon Stanworth
- 0000 0001 0440 1440grid.410556.3Oxford University Hospitals NHS Foundation Trust, Headley Way, Oxford, OX3 9BQ UK
| | - Atholl Johnston
- 0000 0001 2171 1133grid.4868.2William Harvey Research Institute, Heart Centre, Barts and The London School of Medicine, Queen Mary University of London, Charterhouse Square, London, EC1M 6BQ UK
| | - Vivienne Monk
- 0000 0001 2171 1133grid.4868.2Barts Cardiovascular Clinical Trials Unit (CVCTU), William Harvey Research Institute, Heart Centre, Barts and The London School of Medicine, Queen Mary University of London, Charterhouse Square, London, EC1M 6BQ UK
| | - Ben O’Brien
- 0000 0000 9244 0345grid.416353.6St Bartholomew’s Hospital, West Smithfield, London, EC1A 7BE UK
- 0000 0001 0675 4725grid.239578.2Outcomes Research Consortium, Cleveland Clinic, Cleveland, OH USA
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Togashi T, Nagaya S, Nagasawa M, Meguro-Horike M, Nogami K, Imai Y, Kuzasa K, Sekiya A, Horike SI, Asakura H, Morishita E. Genetic analysis of a compound heterozygous patient with congenital factor X deficiency and regular replacement therapy with a prothrombin complex concentrate. Int J Hematol 2019; 111:51-56. [PMID: 31667683 DOI: 10.1007/s12185-019-02767-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 10/16/2019] [Accepted: 10/17/2019] [Indexed: 12/19/2022]
Abstract
Congenital factor X (FX) deficiency is a rare bleeding disorder with an incidence of one in one million. The proband, a 2-year-old girl, exhibited easy bruising and a history of umbilical cord bleeding at birth. Prothrombin time (> 40 s) and activated partial thromboplastin time (65.0 s) were prolonged. Marked declines in FX activity (< 1%) and FX antigen levels (5%) were also observed. Genetic analysis of the proband identified two types of single-base substitutions, c.353G>A (p.Gly118Asp) and c.1303G>A (p.Gly435Ser), indicating compound heterozygous congenital FX deficiency. Genetic analysis of family members revealed that her father and older sister (5-year-old) were also heterozygous for p.Gly118Asp, and that her mother was heterozygous for p.Gly435Ser. To improve the bleeding tendency, the proband received regular replacement of 500 units of PPSB-HT, a prothrombin complex concentrate (PCC). Following continued regular replacement of 500 units of PPSB-HT once per week, the proband has exhibited no bleeding tendencies and no new bruises have been observed. There are no previous report of the use of PPSB-HT for regular FX replacement. Regular replacement therapy with PPSB-HT may be an effective method for preventative control of bleeding tendencies in FX deficiency.
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Affiliation(s)
- Tomoki Togashi
- Department of Laboratory Sciences, School of Health Sciences, College of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Kanazawa, Japan
| | - Satomi Nagaya
- Department of Clinical Laboratory Science, Kanazawa University Graduate School of Medical Science, 5-11-80 Kodatsuno, Kanazawa, 920-0942, Ishikawa, Japan
| | | | | | - Keiji Nogami
- Department of Pediatrics, Nara Medical University Hospital, Kashihara, Nara, Japan
| | - Yuta Imai
- Department of Laboratory Sciences, School of Health Sciences, College of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Kanazawa, Japan
| | - Kana Kuzasa
- Department of Laboratory Sciences, School of Health Sciences, College of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Kanazawa, Japan
| | - Akiko Sekiya
- Department of Clinical Laboratory Science, Kanazawa University Graduate School of Medical Science, 5-11-80 Kodatsuno, Kanazawa, 920-0942, Ishikawa, Japan
| | - Shin-Ichi Horike
- Advanced Science Research Center, Kanazawa University, Kanazawa, Japan
| | - Hidesaku Asakura
- Department of Hematology, Kanazawa University Hospital, Kanazawa, Japan
| | - Eriko Morishita
- Department of Clinical Laboratory Science, Kanazawa University Graduate School of Medical Science, 5-11-80 Kodatsuno, Kanazawa, 920-0942, Ishikawa, Japan. .,Department of Hematology, Kanazawa University Hospital, Kanazawa, Japan.
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Barzilai M, Kirgner I, Steimatzky A, Salzer Gotler D, Belnick Y, Shacham-Abulafia A, Avivi I, Raanani P, Yahalom V, Nakav S, Varon D, Yussim E, Bachar GN, Spectre G. Prothrombin Complex Concentrate before Urgent Surgery in Patients Treated with Rivaroxaban and Apixaban. Acta Haematol 2019; 143:266-271. [PMID: 31610537 DOI: 10.1159/000502173] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2019] [Accepted: 07/06/2019] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Patients treated with direct Xa inhibitors may require urgent surgery. Administration of prothrombin complex concentrate (PCC) in this setting is common; however, it is based on limited experience in healthy volunteers. OBJECTIVE To characterize the population receiving PCC for apixaban/rivaroxaban reversal prior to an urgent surgery and evaluate its efficacy and safety. METHODS This was a retrospective study in 2 tertiary hospitals. Bleeding was evaluated based on surgical reports, hemoglobin drop, and the use of blood products or additional PCC during 48 h. Safety measures were thrombotic complications and 30-day mortality. RESULTS Sixty-two patients aged 80.7 ± 9 years, treated with apixaban (39.63%) or rivaroxaban (23.37%), received PCC before an urgent surgery/procedure. Most underwent abdominal operation (61%), orthopedic surgery (13%), or transhepatic cholecystostomy insertion (10%). Bleeding during surgery was reported in 3 patients (5%), no patient required additional PCC, and 16 patients (26%) received packed cells (median: 1 unit, range: 1-5). The 30-day mortality and thrombosis rates were 21% (n = 13) and 3% (n = 2), respectively. The cause of death was related to the primary disease, most commonly sepsis. No patient died due to bleeding/thrombosis. CONCLUSIONS Our results support the use of PCC to achieve hemostasis in patients treated with Xa inhibitors prior to an urgent surgery.
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Affiliation(s)
- Merav Barzilai
- Institute of Hematology, Sourasky Medical Center, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ilya Kirgner
- Institute of Hematology, Sourasky Medical Center, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Arza Steimatzky
- Institute of Hematology, Rabin Medical Center, Petah Tikva, Israel
| | | | - Yulia Belnick
- Internal Medicine D, Rabin Medical Center, Hasharon Hospital, Petah Tikva, Israel
| | - Adi Shacham-Abulafia
- Institute of Hematology, Rabin Medical Center, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Irit Avivi
- Institute of Hematology, Sourasky Medical Center, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Pia Raanani
- Institute of Hematology, Rabin Medical Center, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Vered Yahalom
- Transfusion and Apheresis Service, Rabin Medical Center, Petah Tikva, Israel
| | - Sigal Nakav
- Hemostasis Laboratory, Rabin Medical Center, Petah Tikva, Israel
| | - David Varon
- Institute of Hematology, Sourasky Medical Center, Tel Aviv, Israel
| | - Ethan Yussim
- Department of Radiology, Sourasky Medical Center, Tel Aviv, Israel
| | - Gil N Bachar
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Radiology, Rabin Medical Center, Petah Tikva, Israel
| | - Galia Spectre
- Institute of Hematology, Rabin Medical Center, Petah Tikva, Israel,
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel,
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Fischer D, Sorensen J, Fontaine GV. Three-Factor Versus Four-Factor Prothrombin Complex Concentrate for the Emergent Management of Warfarin-Associated Intracranial Hemorrhage. Neurocrit Care 2018; 28:43-50. [PMID: 28612131 DOI: 10.1007/s12028-017-0374-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Four-factor prothrombin complex concentrates (PCC) produce a more rapid and complete INR correction compared with 3-factor PCC in patients receiving warfarin. It is unknown if this improves clinical outcomes in the setting of intracranial hemorrhage (ICH). METHODS This multicenter, retrospective cohort study included patients presenting with warfarin-associated ICH reversed with either 4- or 3-factor PCC. The primary outcome was in-hospital mortality. Secondary outcomes were 30-day mortality, discharge location, intensive care unit (ICU) and hospital-free days, INR reversal, and thromboembolic (TE) events at 90 days. Each was analyzed using regression analysis. Continuous and binary outcomes were analyzed using linear and logistic regression, respectively, while ordinal regression was used for discharge location. RESULTS Of the 103 patients, 63 received 4-factor PCC. Median age was 79 years [interquartile intervals(IQI 73-84)], median presenting INR was 2.7 (2.2-3.3), and presenting ICH was intraparenchymal in 51% of patients. In-hospital and 30-day mortality were 25 and 35%, respectively. In-hospital mortality was greater among those who received 4-factor PCC, yet was not statistically significant (OR 2.2, 95% CI 0.59-9.4, p = 0.26), as having Glasgow Coma Scale (GCS) ≤8 explained most of the difference (OR 48, 95% CI 14-219, p <0.001). The effect of 4-factor PCC was not statistically significant in any of the secondary analyses. Crude rates of TE events were higher in the 4-factor PCC group (19 vs. 10%), though not significantly. CONCLUSIONS In-hospital mortality was not improved with the use of 4- versus 3-factor PCC in the emergent reversal of warfarin-associated ICH. Secondary clinical outcomes were similarly nonsignificant.
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Zemrak W, Manuel F, Smith KE, Rolfe S, Hayes T, Trowbridge RL, Carlone B, Seder D. Low-dose compared to manufacturer-recommended dose four-factor prothrombin complex concentrate for acute warfarin reversal. J Thromb Thrombolysis 2019; 47:263-71. [PMID: 30443817 DOI: 10.1007/s11239-018-1768-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Four-factor PCC is the recommended standard of care for acute warfarin reversal but optimal dosing is unknown. We aim to show that a low-dose strategy is often adequate and may reduce the risk of thromboembolic events when compared to manufacturer-recommended dosing. METHODS A weight-based dosing strategy of 15-25 units/kg was established as the institutional standard of care in May 2015. This retrospective, before-and-after cohort analysis included patients receiving 4F-PCC according to a manufacturer-recommended (n = 122) or a low-dose (n = 83) strategy. The primary efficacy outcome was a combination of INR reversal on first check and hemostatic efficacy at 24 h. RESULTS Demographics, indications for warfarin, and presenting INR values were similar between the two groups. Patients in the manufacturer-recommended dose group received significantly more 4F-PCC than the low dose group (2110 units vs. 1530 units). More patients in the manufacturer-recommended dose group achieved the primary endpoint (75.4% vs. 61.4%), with more patients achieving the target INR on recheck in the manufacturer-recommended dose group (95.9% vs. 84.3%) and no difference in hemostatic efficacy between groups (79.5% vs. 74.7%). There was no difference in thromboembolic events at 72 h (4.1% vs. 1.2%) or at 30 days (8.2% vs. 4.8%). Significantly more patients in the manufacturer-recommended dose group died or were transferred to hospice care during hospitalization (21.3% vs. 9.6%). CONCLUSION Utilization of a low-dose 4F-PCC strategy resulted in fewer patients achieving target INR reversal, but no difference in hemostatic efficacy, thromboembolic events, or survival.
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Tischendorf M, Fuchs A, Zeuzem S, Lange CM. Use of prothrombin complex concentrates in patients with decompensated liver cirrhosis is associated with thromboembolic events. J Hepatol 2019; 70:800-1. [PMID: 30630599 DOI: 10.1016/j.jhep.2018.11.019] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 11/15/2018] [Accepted: 11/21/2018] [Indexed: 01/02/2023]
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Sheikh-Taha M. Treatment of apixaban- and rivaroxaban-associated major bleeding using 4-factor prothrombin complex concentrate. Intern Emerg Med 2019; 14:265-269. [PMID: 30414056 DOI: 10.1007/s11739-018-1977-9] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 10/23/2018] [Indexed: 02/06/2023]
Abstract
There is limited clinical experience with the use of coagulation concentrates to reverse the effect of direct oral anticoagulants. We assess the achievement of effective clinical hemostasis with the use of 4-factor prothrombin complex concentrate (PCC) in patients on apixaban or rivaroxaban presenting with major bleeding. A retrospective chart review was conducted at a tertiary referral medical center in the USA. We assess the achievement of clinical hemostasis using 4-factor PCC in patients on chronic apixaban or rivaroxaban therapy presenting with major bleeding. Clinical hemostasis was assessed by the International Society of Thrombosis and Hemostasis Scientific and Standardization Subcommittee criteria. A total of 29 patients are included in the study. The most common site of bleeding was intracranial hemorrhage (ICH) (72.4%), followed by gastrointestinal bleed (13.8%). Clinical hemostasis was achieved in 21 (72.4%) patients. Patients who did not achieve clinical hemostasis (27.6%) suffered from ICH, and all of them died during hospitalization except for two patients who were discharged with neurologic deterioration. One patient developed multiple brain infarctions after receiving 4-factor PCC. Sixteen patients (55.2%) were receiving concomitant medications that interact with apixaban and rivaroxaban and increase the risk of bleeding. Four-factor PCC appears to be effective in achieving clinical hemostasis in patients on apixaban or rivaroxaban presenting with major bleeding. It may be an alternative to patients who need anticoagulation reversal if the specific antidote, andexanet alfa, is not available.
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Affiliation(s)
- Marwan Sheikh-Taha
- Department of Pharmacy Practice, Lebanese American University, Byblos, Lebanon.
- Department of Pharmacy, Huntsville Hospital, Huntsville, AL, USA.
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Xue F, Liu W, Cheng YF, Liu XF, Huang YT, Fu RF, Zhang L, Yang RC. [Immune tolerance induction in a case of hemophilia B with inhibitor with prothrombin complex concentrate and rituximab]. Zhonghua Xue Ye Xue Za Zhi 2019; 38:749-753. [PMID: 29081190 PMCID: PMC7348358 DOI: 10.3760/cma.j.issn.0253-2727.2017.09.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
目的 探讨血友病B伴抑制物的免疫耐受诱导(ITI)治疗,提高血友病B伴抑制物的诊疗水平。 方法 应用基于APTT标准曲线的一期法测定重型血友病B患者凝血因子Ⅸ(FⅨ)活性,应用Bethesda法进行FⅨ抑制物定量测定;利用凝血酶原复合物(PCC)进行ITI并联合利妥昔单抗清除患者抑制物。 结果 患儿既往PCC暴露日为20 d,抑制物滴度峰值为56 BU/ml。在2015年11月患儿抑制物滴度降至10.4 BU/ml时开始ITI治疗,单用PCC一段时间无效,给予PCC联合利妥昔单抗治疗,17个月后成功清除患者体内FⅨ抑制物,未发生过敏反应及肾病综合征等并发症。ITI过程中患者年化出血率有所改善。 结论 该患者是国内首例报道的采用ITI联合利妥昔单抗成功治疗血友病B伴抑制物的病例。PCC联合利妥昔单抗ITI治疗是目前有希望清除血友病B抑制物的方法。
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Affiliation(s)
- F Xue
- State Key Laboratory of Experimental Hematology, Institute of Hematology & Hospital of Blood Diseases, CAMS & PUMC, Tianjin 300020, China
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Zamper RPC, Amorim TC, Queiroz VNF, Lira JDO, Costa LGV, Takaoka F, Juffermans NP, Neto AS. Association between viscoelastic tests-guided therapy with synthetic factor concentrates and allogenic blood transfusion in liver transplantation: a before-after study. BMC Anesthesiol 2018; 18:198. [PMID: 30579327 PMCID: PMC6303918 DOI: 10.1186/s12871-018-0664-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Accepted: 12/03/2018] [Indexed: 02/06/2023] Open
Abstract
Background Perioperative bleeding and transfusion are important causes of morbidity and mortality in patients undergoing liver transplantation. The aim of this study is to assess whether viscoelastic tests-guided therapy with the use of synthetic factor concentrates impact transfusion rates of hemocomponents in adult patients undergoing liver transplantation. Methods This is an interventional before-after comparative study. Patients undergoing liver transplantation before the implementation of a protocol using thromboelastometry and synthetic factor concentrates were compared to patients after the implementation. Primary outcome was transfusion of any hemocomponents. Secondary outcomes included: transfusion of red blood cells (RBC), fresh frozen plasma (FFP), cryoprecipitate or platelets, clinical complications, length of stay and in-hospital mortality. Results A total of 183 patients were included in the control and 54 in the intervention phase. After propensity score matching, the proportion of patients receiving any transfusion of hemocomponents was lower in the intervention phase (37.0 vs 58.4%; OR, 0.42; 95% CI, 0.20–0.87; p = 0.019). Patients in the intervention phase received less RBC (30.2 vs 52.5%; OR, 0.21; 95% CI, 0.08–0.56; p = 0.002) and FFP (5.7 vs 27.3%; OR, 0.11; 95% CI, 0.03–0.43; p = 0.002). There was no difference regarding transfusion of cryoprecipitate and platelets, complications related to the procedure, hospital length of stay and mortality. Conclusions Use of a viscoelastic test-guided transfusion algorithm with the use of synthetic factor concentrates reduces the transfusion rates of allogenic blood in patients submitted to liver transplantation. Trial registration This trial was registered retrospectively on November 15th, 2018 – clinicaltrials.gov – Identifier: NCT03756948. Electronic supplementary material The online version of this article (10.1186/s12871-018-0664-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Raffael P C Zamper
- Department of Transplant Anesthesia, Hospital Israelita Albert Einstein, Rua Galeno de Almeida 107 ap 172-A, Pinheiros, SP, 05410-030, Brazil.
| | - Thiago C Amorim
- Resident of the Anesthesiology Program, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Veronica N F Queiroz
- Resident of the Anesthesiology Program, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Jordana D O Lira
- Resident of the Anesthesiology Program, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Luiz Guilherme V Costa
- Department of Transplant Anesthesia, Hospital Israelita Albert Einstein, Rua Galeno de Almeida 107 ap 172-A, Pinheiros, SP, 05410-030, Brazil
| | - Flavio Takaoka
- Department of Transplant Anesthesia, Hospital Israelita Albert Einstein, Rua Galeno de Almeida 107 ap 172-A, Pinheiros, SP, 05410-030, Brazil
| | - Nicole P Juffermans
- Department of Intensive Care, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Ary S Neto
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil.,Department of Intensive Care, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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Biancari F, Ruggieri VG, Perrotti A, Gherli R, Demal T, Franzese I, Dalén M, Santarpino G, Rubino AS, Maselli D, Salsano A, Nicolini F, Saccocci M, Gatti G, Rosato S, D'Errigo P, Kinnunen EM, De Feo M, Tauriainen T, Onorati F, Mariscalco G. Comparative Analysis of Prothrombin Complex Concentrate and Fresh Frozen Plasma in Coronary Surgery. Heart Lung Circ 2018; 28:1881-1887. [PMID: 30709591 DOI: 10.1016/j.hlc.2018.10.025] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 10/30/2018] [Indexed: 11/18/2022]
Abstract
BACKGROUND Recent studies suggested that prothrombin complex concentrate (PCC) might be more effective than fresh frozen plasma (FFP) to reduce red blood cell (RBC) transfusion requirement after cardiac surgery. METHODS This is a comparative analysis of 416 patients who received FFP postoperatively and 119 patients who received PCC with or without FFP after isolated coronary artery bypass grafting (CABG). RESULTS Mixed-effects regression analyses adjusted for multiple covariates and participating centres showed that PCC significantly decreased RBC transfusion (67.2% vs. 87.5%, adjusted OR 0.319, 95%CI 0.136-0.752) and platelet transfusion requirements (11.8% vs. 45.2%, adjusted OR 0.238, 95%CI 0.097-0.566) compared with FFP. The PCC cohort received a mean of 2.7±3.7 (median, 2.0, IQR 4) units of RBC and the FFP cohort received a mean of 4.9±6.3 (median, 3.0, IQR 4) units of RBC (adjusted coefficient, -1.926, 95%CI -3.357-0.494). The use of PCC increased the risk of KDIGO (Kidney Disease: Improving Global Outcomes) acute kidney injury (41.4% vs. 28.2%, adjusted OR 2.300, 1.203-4.400), but not of KDIGO acute kidney injury stage 3 (6.0% vs. 8.0%, OR 0.850, 95%CI 0.258-2.796) when compared with the FFP cohort. CONCLUSIONS These results suggest that the use of PCC compared with FFP may reduce the need of blood transfusion after CABG.
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Affiliation(s)
- Fausto Biancari
- Heart Center, Turku University Hospital and Department of Surgery, University of Turku, Turku, Finland; Department of Surgery, Oulu University Hospital and University of Oulu, Oulu, Finland.
| | - Vito G Ruggieri
- Division of Cardiothoracic and Vascular Surgery, Robert Debré University Hospital, Reims, France
| | - Andrea Perrotti
- Department of Thoracic and Cardio-Vascular Surgery, University Hospital Jean Minjoz, Besançon, France
| | - Riccardo Gherli
- Department of Cardiovascular Sciences, Cardiac Surgery Unit, S. Camillo-Forlanini Hospital, Rome, Italy
| | - Till Demal
- Hamburg University Heart Center, Hamburg, Germany
| | - Ilaria Franzese
- Division of Cardiovascular Surgery, Verona University Hospital, Verona, Italy
| | - Magnus Dalén
- Department of Molecular Medicine and Surgery, Department of Cardiac Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | | | - Antonino S Rubino
- Centro Clinico-Diagnostico "G.B. Morgagni", Centro Cuore, Pedara, Italy
| | - Daniele Maselli
- Department of Cardiac Surgery, St. Anna Hospital, Catanzaro, Italy
| | - Antonio Salsano
- Division of Cardiac Surgery, University of Genoa, Genoa, Italy
| | | | - Matteo Saccocci
- Department of Cardiac Surgery, Centro Cardiologico - Fondazione Monzino IRCCS, Milan, Italy
| | - Giuseppe Gatti
- Division of Cardiac Surgery, Ospedali Riuniti, Trieste, Italy
| | - Stefano Rosato
- National Center of Global Health, Istituto Superiore di Sanità, Rome, Italy
| | - Paola D'Errigo
- National Center of Global Health, Istituto Superiore di Sanità, Rome, Italy
| | - Eeva-Maija Kinnunen
- Department of Surgery, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Marisa De Feo
- Department of Cardiothoracic Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Tuomas Tauriainen
- Department of Surgery, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Francesco Onorati
- Division of Cardiovascular Surgery, Verona University Hospital, Verona, Italy
| | - Giovanni Mariscalco
- Department of Cardiovascular Sciences, Clinical Sciences Wing, University of Leicester, Glenfield Hospital, Leicester, UK
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Ovesen C, Purrucker J, Gluud C, Jakobsen JC, Christensen H, Steiner T. Prothrombin complex concentrate versus placebo, no intervention, or other interventions in critically bleeding patients associated with oral anticoagulant administration: a protocol for a systematic review of randomised clinical trials with meta-analysis and trial sequential analysis. Syst Rev 2018; 7:169. [PMID: 30342540 PMCID: PMC6195723 DOI: 10.1186/s13643-018-0838-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2018] [Accepted: 10/05/2018] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Acute critical bleeding is one of the most feared complications during treatment with oral anticoagulating agents. As more patients undergo treatment with anticoagulating agents, critically bleeding episodes in patients with vitamin K antagonists, thrombin inhibitor, or factor Xa inhibitor-inducted coagulopathy will be encountered frequently by physicians. Hence, an effective treatment capable of reversing the iatrogenic coagulopathy in the acute setting is needed. In randomised clinical trials and observational studies, prothrombin complex concentrate has been reported to be superior to other acute interventions, and many guidelines recommend prothrombin complex concentrate in treatment of critically bleeding patients. The aim of this systematic review is to synthesise the evidence of the effects of prothrombin complex concentrate compared with placebo, no intervention, or other treatment options in critically bleeding patients treated with oral anticoagulants. METHODS/DESIGN A comprehensive search for relevant published literature will be undertaken in Cochrane Central Register of Controlled Trials, MEDLINE, Embase, WHO International Clinical Trials Registry Platform, Science Citation Index, regulatory databases, and trial registers. We will include randomised clinical trials comparing prothrombin complex concentrate versus placebo, no intervention, or other interventions in critically bleeding patients with oral anticoagulant-induced coagulopathy. Data extraction and risk of bias assessment will be handled by two independent review authors. Meta-analysis will be performed as recommended by Cochrane Handbook for Systematic Reviews of Interventions, bias will be assessed with domains, and trial sequential analysis will be conducted to control random errors. Certainty will be assessed by GRADE. DISCUSSION As critical bleeding in patients treated with oral anticoagulants is an increasing problem, an up-to-date systematic review evaluating the benefits and harms of prothrombin complex concentrate is urgently needed. It is the hope that this review will be able to guide best practice in treatment and clinical research of these critically bleeding patients. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42018084371.
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Affiliation(s)
- Christian Ovesen
- Department of Neurology, Bispebjerg Hospital, University of Copenhagen, Nielsine Nielsensvej 6A & B, DK-2400, Copenhagen, Denmark. .,Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.
| | - Jan Purrucker
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Janus Christian Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.,Department of Cardiology, Holbæk Hospital, Holbæk, Denmark
| | - Hanne Christensen
- Department of Neurology, Bispebjerg Hospital, University of Copenhagen, Nielsine Nielsensvej 6A & B, DK-2400, Copenhagen, Denmark
| | - Thorsten Steiner
- Department of Neurology, Klinikum Frankfurt Höchst, Frankfurt, Germany
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Abstract
4-Factor Prothrombin Complex Concentrate (4F-PCC) is the standard-of-care intervention in patients with major bleeding taking oral vitamin K antagonists. Despite growing clinical experience with 4-FPCC, the optimal dosing strategy remains unclear. In balancing efficacy, safety, and cost of this treatment, many institutions have adopted a low, fixed-dose regimen, with average doses lower than that in the package insert. The fixed-dose 4F-PCC strategy is supported by the available observational studies and case reports; however, the current body of literature is highly heterogenous. The purpose of this narrative review is to address the advantages and shortcomings with clinical use of fixed-dose 4F-PCC, as well as limitations of the available literature. The heterogeneity of the current literature should guide future studies to support or refute this potentially life-saving intervention.
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Zemrak WR, Smith KE, Rolfe SS, May T, Trowbridge RL, Hayes TL, Grindlinger GA, Seder DB. Low-dose Prothrombin Complex Concentrate for Warfarin-Associated Intracranial Hemorrhage with INR Less Than 2.0. Neurocrit Care 2018; 27:334-340. [PMID: 28660341 DOI: 10.1007/s12028-017-0422-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Prothrombin complex concentrates (PCCs) have become the first-line therapy for warfarin reversal in the setting of central nervous system (CNS) hemorrhage. Randomized, controlled studies comparing agents for warfarin reversal excluded patients with international normalized ratio (INR) <2, yet INR values of 1.6-1.9 are also associated with poor outcomes. METHODS We retrospectively reviewed our use of a low-dose (15 units/kg) strategy of 4-factor PCC (4F-PCC) on warfarin reversal (INR 1.6-1.9) in the setting of both traumatic and spontaneous intracranial bleeding. RESULTS A total of 21/134 (15.7%) patients with either spontaneous or traumatic intracranial hemorrhage presented with an INR value of 1.6-1.9. Nine patients (43%) presented with traumatic bleeding and 12 (57%) with spontaneous bleeding. The median (IQR) presenting INR was 1.8 (1.7, 1.9) which decreased to 1.3 (1.2, 1.3) following the administration of low-dose 4F-PCC (median dose = 1062 units; 15.2 units/kg). A total of 19/20 (95%) patients achieved a goal INR value of ≤1.5 on the first check following dosing and 17/20 (85%) achieved an INR value ≤1.3. One patient did not have follow-up INR testing due to withdrawal of life support. No patient experienced hematoma expansion within 48 h of 4F-PCC, and there were no thromboembolic events within 72 h of administration. CONCLUSIONS The administration of low dose (15 units/kg) of 4F-PCC for urgent warfarin reversal in the setting of CNS hemorrhage was effective in correcting the INR in patients presenting with INR values of 1.6-1.9. Further assessment of low-dose PCC for urgent reversal of modest INR elevation is warranted.
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Affiliation(s)
- Wesley R Zemrak
- Department of Pharmacy, Maine Medical Center, 22 Bramhall St, Portland, ME, 04102, USA.
| | - Kathryn E Smith
- Department of Pharmacy, Maine Medical Center, 22 Bramhall St, Portland, ME, 04102, USA
| | - Stephen S Rolfe
- Department of Pharmacy, Maine Medical Center, 22 Bramhall St, Portland, ME, 04102, USA
| | - Teresa May
- Division of Neurocritical Care, Maine Medical Center, Portland, ME, USA
| | | | - Timothy L Hayes
- Department of Pathology, Maine Medical Center, Portland, ME, USA
| | - Gene A Grindlinger
- Division of Surgical Critical Care, Maine Medical Center, Portland, ME, USA
| | - David B Seder
- Division of Neurocritical Care, Maine Medical Center, Portland, ME, USA
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Yasaka M, Brainsky A, Zhang P, Kushimoto S. Coagulation Factor Plasma Levels Following Administration of a 4-Factor Prothrombin Complex Concentrate for Rapid Vitamin K Antagonist Reversal in Japanese Patients. Curr Ther Res Clin Exp 2018; 89:21-26. [PMID: 30224939 PMCID: PMC6139595 DOI: 10.1016/j.curtheres.2018.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Revised: 08/14/2018] [Accepted: 08/21/2018] [Indexed: 12/02/2022] Open
Abstract
Background Four-factor prothrombin complex concentrates (4F-PCCs) have been approved for urgent vitamin K antagonist reversal in Western countries for many years. Ethnicity and genetic variations between populations may influence the pharmacokinetic profile of 4F-PCC treatments. Objective To report plasma levels of vitamin K-dependent coagulation factors and proteins C and S in Japanese patients following administration of a 4F-PCC approved recently in Japan. Methods This was a subanalysis of a prospective, open-label, Phase IIIb study in Japanese patients requiring rapid vitamin K antagonist reversal owing to major bleeding (n = 6) or need for urgent surgery (n = 5). International normalized ratio and plasma levels of factors II, VII, IX, and X, and proteins C and S were measured before PCC infusion and at specific time points for the next 24 hours. Adverse events and serious adverse events were recorded up to Day 14 and 45, respectively. Results Rapid increases in plasma concentrations 30 minutes following 4F-PCC infusion were seen for all factors and proteins C and S, with median concentrations compared with baseline increasing by ≥100% and 70% in the bleeding and surgical groups, respectively. A concurrent decrease in international normalized ratio was observed. Plasma levels for each factor and protein remained within physiologic levels throughout the assessment period. No relationship between thromboembolic events and elevated plasma levels was identified. Conclusions Administration of 4F-PCC in Japanese patients receiving vitamin K antagonist anticoagulation therapy resulted in rapid and sustained increases in plasma levels and was well tolerated, indicating that this treatment is effective for the urgent reversal of vitamin K antagonist therapy in this population.
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Affiliation(s)
- Masahiro Yasaka
- National Hospital Organization, Kyushu Medical Center, Fukuoka, Japan
| | | | | | - Shigeki Kushimoto
- Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
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Brekelmans MPA, Ginkel KV, Daams JG, Hutten BA, Middeldorp S, Coppens M. Benefits and harms of 4-factor prothrombin complex concentrate for reversal of vitamin K antagonist associated bleeding: a systematic review and meta-analysis. J Thromb Thrombolysis 2018; 44:118-129. [PMID: 28540468 PMCID: PMC5486892 DOI: 10.1007/s11239-017-1506-0] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Prothrombin complex concentrate (PCC) is used for reversal of vitamin K antagonists (VKA) in patients with bleeding complications. This study aims to assess benefits and harms of 4-factor PCC compared to fresh frozen plasma (FFP) or no treatment in VKA associated bleeding. PubMed, EMBASE and CENTRAL were searched from 1945 to August 2015. Studies reporting 4-factor PCC use for VKA associated bleeding and providing data on INR normalization, mortality or thromboembolic (TE) complications were eligible. Two authors screened titles and full articles for inclusion, extracted data, and assessed risk of bias. Mortality data were pooled using Mantel–Haenszel random effects meta-analysis. Nineteen studies were included (N = 2878); 18 cohort studies and one RCT. Six studies had good methodological quality, 9 moderate and 4 poor. Baseline INR values ranged from 2.2 to >20. The INR within 1 h after PCC administration ranged from 1.4 to 1.9, and after FFP administration from 2.2 to 12. PCC reduced the time to reach INR correction in comparison with FFP or no treatment. The observed mortality rate ranged from 0 to 43% (mean 17%) in the PCC, 4.8–54% (mean 16%) in the FFP and 23–69% (mean 51%) in the no treatment group. Meta-analysis of mortality data resulted in an OR of 0.64 (95% confidence interval [CI] 0.27–1.5) for PCC versus FFP and an OR 0.41 (95% CI 0.13–1.3) for PCC versus no treatment. TE complications were observed in 0–18% (mean 2.5%) of PCC and in 6.4% of FFP recipients. Four-factor PCC is an effective and safe option in reversal of VKA bleeding events.
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Affiliation(s)
- Marjolein P A Brekelmans
- Department of Vascular Medicine, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands.
| | | | - Joost G Daams
- Medical Library, Academic Medical Center, Amsterdam, the Netherlands
| | - Barbara A Hutten
- Department of Clinical Epidemiology, Academic Medical Center, Amsterdam, the Netherlands
| | - Saskia Middeldorp
- Department of Vascular Medicine, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands
| | - Michiel Coppens
- Department of Vascular Medicine, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands
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45
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Katayama H, Nagao A, Hosokai R, Suzuki T. [Successful long-term management of ovarian bleeding and menorrhagia with prothrombin complex concentrate in a patient with congenital factor X deficiency]. Rinsho Ketsueki 2018; 59:2428-2431. [PMID: 30531138 DOI: 10.11406/rinketsu.59.2428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
A female patient in her forties exhibited no evidence of abnormal bleeding at birth. At the age of 6 years, she experienced pain in bilateral thighs and knee joints without any occasion. Accordingly, the bleeding tendency was suspected, and the coagulation profile assessment revealed prolongation of the APTT (122 s). Further tests revealed a marked reduction in the factor X activity (FX:C) to 4.5%, and the patient was diagnosed with congenital factor X deficiency; at that time, the case was reported by Mori et al. (The Japanese Society of Hematology 43: 572-586, 1980). At the age of 19 years, she was transferred to our hospital, where both prolongation of the PT and APTT and reduction of FX:C to <1% were reconfirmed. During follow-up observation, the patient developed lower abdominal pain and severe anemia. Gynecological examination revealed ovarian bleeding with menorrhagia. Thus, she was prescribed low-dose pills for menorrhagia, which successfully arrested the progression of anemia for a long term. However, she underwent uterine myomectomy and developed anemia again because of menorrhagia. For controlling menorrhagia-caused severe anemia, we initiated the patient on FX replacement therapy with prothrombin complex concentrate, PPSB-HT "Nichiyaku," by self-infusion on day 1 of each monthly menstrual cycle. Since then, menorrhagia and severe anemia have remained under good control.
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Affiliation(s)
| | - Azusa Nagao
- Department of Blood Coagulation, Ogikubo Hospital
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46
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Carothers C, Giancarelli A, Ibrahim J, Hobbs B. Activated prothrombin complex concentrate for warfarin reversal in traumatic intracranial hemorrhage. J Surg Res 2018; 223:183-7. [PMID: 29433872 DOI: 10.1016/j.jss.2017.11.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Revised: 10/10/2017] [Accepted: 11/03/2017] [Indexed: 01/29/2023]
Abstract
BACKGROUND Patients with traumatic intracranial hemorrhage (TIH) anticoagulated with warfarin are at an increased risk of mortality. Fresh frozen plasma (FFP) and vitamin K have been the standard treatment for warfarin reversal; however, guidelines now recommend the use of prothrombin complex concentrate (PCC) for warfarin reversal in patients with life-threatening bleeding. Our protocol uses one vial (∼1000 units) of activated PCC (aPCC) for warfarin reversal, regardless of the weight or presenting international normalized ratio (INR). The purpose of this study was to determine the safety and efficacy of using fixed, low-dose aPCC for warfarin reversal in patients with TIH. METHODS This was a retrospective chart review that included patients with an Abbreviated Injury Scale Head score of ≥3, TIH, and initial INR ≥ 1.5 on warfarin. Patients aged <18 years and those with no repeat INR were excluded. The primary outcome was to compare the percentage of patients with INR ≤ 1.4 after receiving aPCC versus FFP within 24 hours. RESULTS Eighty-nine patients were in the FFP group and 31 patients in the aPCC group. The INR was reversed more effectively in the aPCC group compared with the FFP group (90.3% versus 69.7%, P = 0.029). The median time (hours) to reversal was also significantly shorter in the aPCC group compared with the FFP group (3.75 versus 6.75, P = 0.003). However, there was no difference in mortality (35.5% aPCC versus 22.2% control, P = 0.162) or incidences of thrombosis. CONCLUSION Fixed, low-dose aPCC is safe and more effective at reversing the effects of warfarin than FFP in patients with TIH.
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Abdoellakhan RA, Miah IP, Khorsand N, Meijer K, Jellema K. Fixed Versus Variable Dosing of Prothrombin Complex Concentrate in Vitamin K Antagonist-Related Intracranial Hemorrhage: A Retrospective Analysis. Neurocrit Care 2017; 26:64-69. [PMID: 27052728 PMCID: PMC5226998 DOI: 10.1007/s12028-016-0248-8] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Millions of patients receive vitamin K antagonist (VKA) therapy worldwide. Annually 0.2-1 % of all VKA users develops an intracranial hemorrhage (ICH). Prothrombin complex concentrate (PCC) is administered to restore the INR ≤ 1.5 in an attempt to limit hematoma growth. In order to facilitate PCC dosing, our hospital recently changed from a variable dose based on bodyweight, baseline- and target-INR, to a fixed 1000 IU fIX PCC dosing protocol for ICH. METHODS In a before and after design, we compared successful achievement of an INR ≤ 1.5 with a fixed dosing strategy versus the variable dosing strategy of PCC in patients presenting with intracranial bleeding complications of VKA. Data of the two cohorts of patients were retrospectively collected from medical records. RESULTS A median dosage of 1750 IU was given per patient in the variable dose group (n = 25) versus 1000 IU in the fixed dose group (n = 28). In the intention-to-treat analysis, 96 % achieved an INR ≤ 1.5 after an initial dose in the variable dose cohort compared to 68 % in the fixed dose cohort (p = 0.01). An additional dose was given in 2 (8 %) versus 9 (32 %) patients, respectively (p = 0.04). The median door-to-PCC-order time was 42 versus 32 min (p = 0.37) and the door-to-needle time was 81, respectively 60 min (p = 0.42). CONCLUSION The fixed dose protocol necessitates additional PCC infusions more frequently to achieve a target INR ≤ 1.5. Door-to-order and door-to-needle time were shorter but, in this small cohort, not significantly so. The effect on clinical outcome remains unknown.
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Affiliation(s)
- Rahat Amadkhan Abdoellakhan
- Department of Haematology, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands. .,Department of Pharmacy, Apotheek Haagse Ziekenhuizen, The Hague, The Netherlands.
| | - Ishita Parveen Miah
- Department of Neurology, Medical Center Haaglanden, The Hague, The Netherlands
| | - Nakisa Khorsand
- Department of Pharmacy, Apotheek Haagse Ziekenhuizen, The Hague, The Netherlands
| | - Karina Meijer
- Department of Haematology, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - Korné Jellema
- Department of Neurology, Medical Center Haaglanden, The Hague, The Netherlands
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Abstract
The use of anticoagulation in the prevention of strokes due to atrial fibrillation or the treatment of venous thromboembolic disease has been on the rise. With the advent and proliferation of direct oral anticoagulation medications, the management of anticoagulation reversal has become increasingly complex, especially when urgent or emergent reversal is required. This review details the commonly used parenteral and oral anticoagulants, the treatment strategies necessary for their reversal, and therapies still in development.
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Affiliation(s)
- Jeremy L Holzmacher
- Center for Trauma and Critical Care, Department of Surgery, George Washington University Medical Center, 2150 Pennsylvania Avenue Northwest, Suite 6B, Washington, DC 20037, USA
| | - Babak Sarani
- Center for Trauma and Critical Care, Department of Surgery, George Washington University Medical Center, 2150 Pennsylvania Avenue Northwest, Suite 6B, Washington, DC 20037, USA.
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49
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Abstract
Primary intracerebral hemorrhage (ICH) is a common, devastating disease that lacks an effective specific treatment. Mortality is high, functional outcomes are poor, and these have not substantially changed for decades. There is, therefore, considerable opportunity for advancement in the management of ICH. In recent years, a significant amount of research has begun to address this gap. This article is aimed at updating neurologists on the most clinically relevant contemporary research.
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50
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Kushimoto S, Fukuoka T, Kimura A, Toyoda K, Brainsky A, Harman A, Chung T, Yasaka M. Efficacy and safety of a 4-factor prothrombin complex concentrate for rapid vitamin K antagonist reversal in Japanese patients presenting with major bleeding or requiring urgent surgical or invasive procedures: a prospective, open-label, single-arm phase 3b study. Int J Hematol 2017; 106:777-786. [PMID: 28815410 DOI: 10.1007/s12185-017-2311-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Revised: 08/03/2017] [Accepted: 08/03/2017] [Indexed: 11/30/2022]
Abstract
Rapid vitamin K antagonist (VKA) reversal is required in patients experiencing major bleeding or requiring urgent surgery. Four-factor prothrombin complex concentrate (4F-PCC; Beriplex®/Kcentra®) was shown in two large randomized controlled, international phase 3b trials to be an effective alternative to plasma for urgent VKA reversal. In the present prospective, open-label, single-arm phase 3b trial, we evaluate the efficacy and safety of 4F-PCC in Japanese patients. Eleven patients [international normalized ratio (INR) ≥2] requiring rapid VKA reversal owing to major bleeding (n = 6) or before urgent surgical/invasive procedures (n = 5) were administered 4F-PCC dosed based on INR and weight. INR reduction (≤1.3 0.5 h postinfusion; primary endpoint) was achieved in 81.8% of patients (major bleeding, 83.3%; surgical/invasive procedures, 80.0%). Effective hemostasis (main secondary endpoint) was met in 60.0% (major bleeding) and 100% (surgical/invasive procedure) of evaluable patients. Adverse events (AEs) and serious AEs were reported in 90.9 and 45.5% of patients, respectively. Two AEs were considered treatment-related; thromboembolic events rated mild and not clinically relevant by investigators. There were no deaths, fluid overload events, or viral transmission cases. Consistent with the previous results, 4F-PCC may be an effective and well-tolerated treatment for rapid VKA reversal in Japanese patients experiencing major bleeding or requiring urgent surgical/invasive procedures.
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Affiliation(s)
- Shigeki Kushimoto
- Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | | | - Akio Kimura
- Center Hospital, National Center for Global Health and Medicine, Tokyo, Japan
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | | | | | | | - Masahiro Yasaka
- National Hospital Organization, Kyushu Medical Center, Fukuoka, Japan.
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