Volume 200 - Issue 2
An update of consensus guidelines for warfarin reversal
Authors: Huyen A Tran, Sanjeev D Chunilal and Huy Tran
Med J Aust 2014; 200 (2): 82. || doi: 10.5694/mja13.10685
Published online: 3 February 2014
Published online: 3 February 2014
In reply: Badami suggests that international normalised ratio
(INR)-based prothrombin complex concentrate (PCC) dosing for warfarin reversal may not be clinically useful and is cumbersome to use. We agree that the INR variably reflects factor II, VII, IX and X activity in patients on warfarin therapy. However, the INR is a rapid, valid and readily available test, and an INR-based PCC dosing regimen provides guidance ...
In reply: Badami suggests that international normalised ratio (INR)-based prothrombin complex concentrate (PCC) dosing for warfarin reversal may not be clinically useful and is cumbersome to use. We agree that the INR variably reflects factor II, VII, IX and X activity in patients on warfarin therapy. However, the INR is a rapid, valid and readily available test, and an INR-based PCC dosing regimen provides guidance on how to manage patients on warfarin therapy who have major bleeds or need urgent surgery. We acknowledge that further validation of the INR-based dosing regimen is needed, but only a randomised trial comparing INR-based dosing with fixed-dose PCC treatment will give clarity.
We appreciate that randomised trials involving warfarinised patients and comparing the efficacy of three-factor versus four-factor PCC are lacking, but existing evidence from observational studies shows that three-factor PCC is efficacious and safe.1,2 Specifically, three-factor PCC in patients with warfarin-related intracranial haemorrhage has been shown to be associated with an improved outcome, suggesting that the lack of factor VII may not be critical.3
Competing interests
No relevant disclosures.
References
- Kruger PC, Le Viellez AS, Herrmann RP. Prothrombinex-VF use in warfarin reversal and other indications. Med J Aust 2012; 196: 462-465. 0_CHDEBDID
- Tran H, Collecutt M, Whitehead S, Salem HH. Prothrombin complex concentrates used alone in urgent reversal of warfarin anticoagulation. Intern Med J 2011; 41: 337-343. 0_CBBDFIDI
- Hanger HC, Geddes JA, Wilkinson TJ, et al. Warfarin-related intracerebral haemorrhage: better outcomes when reversal includes prothrombin complex concentrates. Intern Med J 2013; 43: 308-316. 0_CBBHEIDG