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Initiation of a fixed-dose four-factor prothrombin complex concentrate protocol

  • L. FuhEmail author
  • J. N. Goldstein
  • B. D. Hayes
Article

Abstract

Patients who require urgent warfarin reversal often receive four-factor prothrombin complex concentrate (4F-PCC), which is traditionally dosed according to weight and initial INR. Our institution implemented a fixed-dose 4F-PCC strategy, using an initial dose of 1500 units. We evaluated the frequency with which the initial fixed dose 4F-PCC was inadequate, as defined by need for supplemental dosing. As part of the protocol, if the initial fixed-dose 4F-PCC is administered and does not achieve INR goal, then the remainder of the standard weight- and INR-based dosing can be given. During the study period, 63 patients on warfarin received 4F-PCC using the fixed-dose protocol. Based on the INR following 4F-PCC administration, 11 patients (17%) were eligible to receive a supplemental dose based on failure to achieve their specified INR goal. Two of the 11 patients eligible for supplemental 4F-PCC dosing received the second dose, both with initial supratherapeutic INRs > 3.5. We found that most patients given an initial fixed-dose 4F-PCC achieved their INR goals, and of those who did not, most did not receive supplemental dosing, suggesting that clinical providers felt that adequate hemostasis had been achieved. In addition, fixed-dose 4F-PCC was able to be given rapidly, with few dosing errors, suggesting that this is a reasonable option for 4F-PCC delivery.

Keywords

Four-factor prothrombin complex concentrate Fixed-dose Protocol Supplemental dosing 

Notes

References

  1. 1.
    Corio JL, Sin JH, Hayes BD, Goldstein JN, Fuh L (2018) Impact of a pharmacist-driven prothrombin complex concentrate protocol on time to administration in patients with warfarin-associated intracranial hemorrhage. West J Emerg Med. 19(5):849–854CrossRefGoogle Scholar
  2. 2.
    Tomaselli GF, Mahaffey KW, Cuker A et al (2017) 2017 ACC expert consensus decision pathway on management of bleeding in patients on oral anticoagulants: a report of the American College of Cardiology Task Force on Expert Consensus Decision Pathways. J Am Coll Cardiol 70(24):3042–3067CrossRefGoogle Scholar
  3. 3.
    Klein L, Peters J, Miner J, Gorlin J (2015) Evaluation of fixed dose 4-factor prothrombin complex concentrate for emergent warfarin reversal. Am J Emerg Med 33(9):1213–1218CrossRefGoogle Scholar
  4. 4.
    Varga C, Al-Touri S, Papadoukakis S, Caplan S, Kahn S, Blostein M (2013) The effectiveness and safety of fixed low-dose prothrombin complex concentrates in patients requiring urgent reversal of warfarin. Transfusion. 53(7):1451–1458CrossRefGoogle Scholar
  5. 5.
    Abdoellakhan RA, Miah IP, Khorsand N, Meijer K, Jellema K (2017) Fixed versus variable dosing of prothrombin complex concentrate in vitamin K antagonist-related intracranial hemorrhage: a retrospective analysis. Neurocrit Care 26(1):64–69CrossRefGoogle Scholar
  6. 6.
    Wozniak M, Kruit A, Padmore R, Giulivi A, Bormanis J (2012) Prothrombin complex concentrate for the urgent reversal of warfarin. Assessment of a standard dosing protocol. Transfus Apher Sci. 46:309–314CrossRefGoogle Scholar
  7. 7.
    Khorsand N, Veeger NJ, van Hest RM, Ypma PF, Heidt J, Meijer K (2012) 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. Haematologica 97(10):1501–1506CrossRefGoogle Scholar
  8. 8.
    Frontera JA, Lewin JJ III, Rabinstein AA et al (2016) Guideline for reversal of antithrombotics in intracranial hemorrhage: a statement for healthcare professionals from the Neurocritical Care Society and Society of Critical Care Medicine. Neurocrit Care 24:6–46CrossRefGoogle Scholar
  9. 9.
    Kcentra® [package insert]. Kankakee, IL: CSL Behring LLC; 2018Google Scholar
  10. 10.
    Hirri HM, Green PJ (2014) Audit of warfarin reversal using a new Octaplex reduced dose protocol. Transfus Apher Sci. 51(2):141–145CrossRefGoogle Scholar
  11. 11.
    Astrup G, Sarangarm P, Burnett A (2018) Fixed dose 4-factor prothrombin complex concentrate for the emergent reversal of warfarin: a retrospective analysis. J Thromb Thrombolysis 45:300–305CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of PharmacyMassachusetts General HospitalBostonUSA
  2. 2.Department of Emergency MedicineMassachusetts General HospitalBostonUSA

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