How I treat warfarin-associated coagulopathy in patients with intracerebral hemorrhage

Abstract

Intracerebral hemorrhage in patients with warfarin-associated coagulopathy is an increasingly common life-threatening condition that requires emergent management. The evolution of therapeutic options in this setting, as well as recently published guidelines, has resulted in some heterogeneity in recommendations by professional societies. This heterogeneity can be attributed to lack of evidencebased support for plasma therapy; the variability in availability of prothrombin complex concentrates; the variability in the coagulation factor levels and contents of prothrombin complex concentrates; ambiguity about the optimal dose and route of administration of vitamin K; and the lack of standardized clinical care pathways, particularly in community hospitals, for the management of these critical care patients. In this review, we summarize the relevant literature about these controversies and present recommendations for management of patients with warfarin-associated coagulopathy and intracerebral hemorrhage.(Blood. 2011; 117(23):6091-6099)

An observational, prospective, two-cohort comparison of a fixed versus variable dosing strategy of prothrombin complex concentrate to counteract vitamin K antagonists in 240 bleeding emergencies

“…Even though new oral anticoagulants are entering routine clinical practice, it is likely that VKA and PCC will still be used extensively over the next few years (and possibly longer). Therefore, the need for well-defined strategies for emergent PCC therapy is still relevant, 22 particularly since PCC may be used as an antidote for some of the new oral anticoagulants. 23 Although the low fixed dose is inferior in reaching the target INR in patients with a baseline INR above 7.5, we advocate immediate treatment of all patients entering the emergency department with a major or clinically relevant VKA-associated non-intracranial bleeding event with a low fixed dose of 1,040 IU F IX.…”

Retrospective study of rFVIIa, 4‐factor PCC, and a rFVIIa and 3‐factor PCC combination in improving bleeding outcomes in the warfarin and non‐warfarin patient

“…Although any person can suffer a lifethreatening hemorrhage, patients on warfarin are at an increased risk due to their decreased ability to form thrombosis [1]. Warfarin patients are at particular risk for intracranial hemorrhage (ICH), which has high mortality rates [2]. It is, therefore, important for physicians to rapidly and effectively stop bleeding, and if necessary reverse warfarin.…”

“…FFP has been the standard therapy prior to the advent of rFVIIa due to its wide availability, but it requires thawing, matching to the patient's blood type, and use of a large volume, which can cause intravascular volume overload and heart failure, particularly in elderly patients [2,3]. FFP also carries the risk of transfusion-related acute lung injury (TRALI), with constraints meant to reduce TRALI occurrence reducing FFP availability [2].…”

“…FFP has been the standard therapy prior to the advent of rFVIIa due to its wide availability, but it requires thawing, matching to the patient's blood type, and use of a large volume, which can cause intravascular volume overload and heart failure, particularly in elderly patients [2,3]. FFP also carries the risk of transfusion-related acute lung injury (TRALI), with constraints meant to reduce TRALI occurrence reducing FFP availability [2]. In contrast, PCC, which only became widely used for warfarin reversal in the past decade, is available in smaller volumes and does not require matching or thawing, but is more expensive and may result in higher incidences of thromboembolic events [3].…”

“…Used in conjunction with many of these other therapies but specifically for warfarin patients, vitamin K can be used to reverse warfarin-related coagulopathy, but due to the length of time required for it to have an effect is not recommended alone for treating life-threatening hemorrhage [2]. FFP has been the standard therapy prior to the advent of rFVIIa due to its wide availability, but it requires thawing, matching to the patient's blood type, and use of a large volume, which can cause intravascular volume overload and heart failure, particularly in elderly patients [2,3].…”