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Superwarfarins are anticoagulant rodenticides similar to warfarin, but which have various substituted phenyl groups replacing the terminal methyl group, resulting in a fat-soluble, long-acting anticoagulant that is nearly 100 times more potent than the parent compound. Since their development, many accidental and intentional cases of consumption have been reported. We describe two cases of consumption, one related to unknown etiology, and the other related to utilization of the superwarfarin to potentiate a drug of abuse. The clinical manifestations including bleeding symptoms and abnormal coagulation assays are discussed. The differential diagnosis is quite broad, and includes all causes of vitamin K deficiency, factor deficiency or inhibitor, disseminated intravascular coagulation (DIC), and liver disease. Differentiating superwarfarin ingestion from the other causes can be quite difficult, but extremely important, as management requires prolonged administration of vitamin K. Other treatment options are discussed as well including, fresh frozen plasma (FFP), and recombinant factor VIIa. Finally, the significance of ''lacing'' drugs of abuse with superwarfarin to potentiate their effect is discussed, as well as the complications that could develop from such a habit. Am. J. Hematol. 82:656-660, 2007. V V C 2006 Wiley-Liss, Inc.

We performed a retrospective review of patients with immune-mediated thrombocytopenia (ITP) treated with prolonged infusions of intravenous immunoglobulin (IVIg) (1 g/kg by continuous infusion over 24 hr) and concurrent platelets (1 pheresis unit every 8 hr), to determine the response rate of this therapy. Patient inclusion criteria included clinically significant thrombocytopenia, with either active bleeding, need for anticoagulation, or a needed surgical procedure. The average pretreatment platelet count was 10,000/microl, which increased to 55,000/microl after 24 hr and 69,000/microl after 48 hr. After 24 hr, 62.7% of patients had a platelet count >50,000/microl. Bleeding was controlled initially in all patients, and those requiring a procedure experienced no bleeding complications. Over half of the patients (52.5%) required additional treatments for recurrent or refractory ITP. Six of the 21 patients requiring retreatment (29%) received IVIg and platelets again in a similar fashion, with similar results. No side effects of the combined treatment were noted. There is limited literature on the optimal dose and schedule for administration of IVIg and platelets. Our approach for administration of IVIg and platelets concurrently was associated with minimal side effects, resolution of bleeding, ability to safely undergo procedures, and rapid restoration of adequate platelet counts.