WARFARIN REVERSAL – When and How?

10 Jul
submitted by Amit Kumar, M.D. 
 
SERIOUS LIFE-THREATENING BLEEDING:
-Hold warfarin
-Vit K 10mg IV infusion over 20-60minsholygrail018
-PCC. Dosing based on weight and INR. Typical for INR >6: 50 U/kg. Re-check INR 30 mins post-admin.
-Transfusions: RBC, Platelets (if <50,000), FFP (15-30cc/kg; if PCC unavailable)
-Other agents: TXA/aminocaproic acid (anti-fibrinolytic), DDAVP (for platelet dysfunction)
 
URGENT SURGERY/PROCEDURE:
-Hold warfarin. Vit K + PCC, as above
 
SURGERY/PROCEDURE after 24H:
-Hold warfarin. Vit K 1-2mg
 
MINIMAL BLEEDING:
-Clinical judgement: withhold warfarin vs hold warfarin + Vit K vs more aggressive reversal (like above)
-Weigh pros/cons of current bleeding vs thromboembolic risk
 
NO BLEEDING:
-INR >9:  Vit K 2.5-5mg PO. Will reduce INR over 24-48 h. Can re-start warfarin (maybe reduced dose) when INR therapeutic
-INR 5-9: Hold warfarin temporarily (1-2 doses) +/- Vit K 1-2.5mg (elderly with slower clearance, prior bleeding)
-INR <5: Hold next dose of warfarin
 
SUPERWARFARIN POISONING:
-Often found in rodenticides, laced street-drugs. Accidental vs suicide attempt.
-Usually requires massive doses of Vit K (50-800mg/d) for months-years, based on repeat assays and coagulation studies
————————————————————————————————–
PCC pearls:
-If 4-factor PCC missing, use 3-factor PCC + FFP (to supplement factor VII)
-PCC dose based on units of factor IX activity
-PCC advantage over FFP: more rapid admin (doesn’t have to be thawed), faster INR reversal, lower risks for volume overload or TRALI
 
References:
“Paper Chase 1- PCC vs. FFP.” Review. Audio blog post. Www.emrap.org. EM:RAP, Dec. 2013. Web. <https://www.emrap.org/episode/december2013/paperchase1pcc>. Episode 147
 
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