Management of patients on Warfarin with bleeding

 

Clinical setting

Recommendation

INR >1.5 with life-threatening  (critical organ) bleeding

Cease Warfarin

Administer:

·         Vitamin K 5.0 – 10.0 mg i.v.

·         and Prothrombinex-VF 50 IU/kg i.v.

·         and fresh frozen plasma 150 – 300 ml i.v.

·          

If prothrombinex-VF is unavailable administer fresh frozen plasma 15ml/kg

INR >2.0 with clinically significant bleeding

Cease Warfarin

Administer:

·         Vitamin K 5.0 – 10.0 mg i.v.

·         and Prothrombinex-VF 35 - 50 IU/kg i.v. according to INR (see table below).

 

If Prothrombinex-VF is unavailable administer fresh frozen plasma 15ml/kg

Any INR with minor bleeding

Omit Warfarin

Repeat INR next day and adjust dose to maintain INR within the therapeutic range.

If the bleeding risk is high or INR >4.5 consider vitamin K 1.0 – 2.0 mg orally or 0.5 – 1.0mg iv.

 

Tran HA, Chunilal SD, Harper PL, et al. An update of consensus guidelines for warfarin reversal. Med J Aust 2013; 198 (4): 198-199. © Copyright 2013 The Medical Journal of Australia - reproduced with permission

 

The guidelines recommend the use of both Prothrombinex-VF and fresh frozen plasma for life threatening bleeding. In all other situations Prothrombinex alone is sufficient treatment.

 

Prothrombinex is a three factor concentrate containing factors II, IX and X, however the product only has a trace amount of factor VII. In the past there has been concern that the three factor concentrate may not be sufficient to correct an elevated INR alone and treatment has been combined with FFP to replace the factor VII.

 

Recent studies have shown that Prothrombinex alone is sufficient to correct an elevated INR but the data to support this comes from patients with a moderately elevated INR, there were few patients in these series with an INR approaching 10.  Therefore to ensure adequate replacement even in the presence of a high INR, the guidelines recommend combining FFP with Protrombinex-VF in life-threatening bleeds.

 

Suggested dose of Prothrombinex-VF to reverse Warfarin according to the initial and target INR

 

Prothrombinex-VF is available in 500iu vials.

 

Initial INR

Target INR

1.5 – 2.5

2.6 – 3.5

3.6 – 10.0

>10.0

0.9 – 1.3

30 IU/kg

35 IU/kg

50 IU/kg

50 IU/kg

1.4 – 2.0

15 IU/kg

25 IU/kg

30 IU/kg

40 IU/kg

 

Tran HA, Chunilal SD, Harper PL, et al. An update of consensus guidelines for warfarin reversal. Med J Aust 2013; 198 (4): 198-199. © Copyright 2013 The Medical Journal of Australia - reproduced with permission