Key result
Three-factor PCC alone lowered INR to <3.0 in only 43-50% of patients versus 63% with plasma alone, but adding supplemental plasma to PCC increased the success rate to 88-89%.
Why the study?
Does three-factor prothrombin complex concentrate improve the rate of INR correction compared to plasma alone in patients with warfarin overdose?
Observational (n=82)
Does three-factor prothrombin complex concentrate improve the rate of INR correction compared to plasma alone in patients with warfarin overdose?
Three-factor PCC alone is suboptimal for urgent warfarin reversal due to low Factor VII content, but its efficacy is significantly improved when supplemented with a small amount of plasma.
Three-factor PCC alone may inadequately reverse INR; leaves open whether plasma supplementation improves outcomes in prospective trials.
BACKGROUND: Plasma transfusion is standard therapy for urgent warfarin reversal in the United States. "Four-factor" prothrombin complex concentrate (PCC), available in Europe, has advantages over plasma therapy for warfarin reversal; however, only "three-factor" PCCs (containing relatively low Factor [F]VII) are available in the United States. STUDY DESIGN AND METHODS: The efficacy of a three-factor PCC for urgent warfarin reversal was evaluated in 40 patients presenting with supratherapeutic international normalized ratio (ST-INR > 5.0) with bleeding (n = 29) or at high risk for bleeding (n = 11). In 13 patients, pre- and posttherapy vitamin K-dependent factors were assayed. Historical controls (n = 42) treated with plasma alone were used for rate of ST-INR correction comparison. RESULTS: Treatment with plasma alone (mean, 3.6 units) lowered the INR to less than 3.0 in 63 percent of historical controls. Low-dose (25 U/kg) and high-dose (50 U/kg) PCC alone lowered INR to less than 3.0 in 50 and 43 percent of patients, respectively. Additional transfusion of a small amount of plasma (mean, 2.1 units) increased the rate of achieving an INR of less than 3.0 to 89 and 88 percent for low- and high-dose PCC therapy, respectively. FII, F IX, and FX increments were similar for PCC-treated patients with or without supplemental plasma; FVII was significantly higher in the PCC plus plasma group compared to the PCC-only group (p = 0.001). CONCLUSION: Three-factor PCC does not satisfactorily lower ST-INR due to low FVII content. Infusion of a small amount of plasma increases the likelihood of satisfactory INR lowering.
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Holland et al. (2009) conducted an observational in Supratherapeutic international normalized ratio (INR > 5.0) due to warfarin overdose (n=82). Three-factor prothrombin complex concentrate (PCC) with or without supplemental plasma vs. Plasma alone (historical controls) was evaluated on Lowering INR to less than 3.0. Three-factor PCC alone lowered INR to <3.0 in only 43-50% of patients versus 63% with plasma alone, but adding supplemental plasma to PCC increased the success rate to 88-89%.
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