Audit of warfarin reversal using a new Octaplex reduced dose protocol.

INTRODUCTION: Prothrombin Complex Concentrate (PCC) is increasingly used for the emergency reversal of the effects of Vitamin K antagonists due to the increased use of the latter. There is no consensus on dosage protocols for its use. There is evidence that small fixed doses are effective. We report the result of the use of a simple three dose level protocol i.e. 2000 IU for CNS bleeds, 1500 IU for other bleeds and 1000 IU for non bleeders. METHODS: Data was prospectively collected over a 6 month period on all patients receiving PCC (Octaplex). These included clinical indication, dose given, INR test results, delay in treatment, and patients' demographics. RESULTS: The protocol was followed in only 40%; 24% were given a larger dose and 35% a smaller dose than we recommended. Despite this the INR was corrected (≤1.5) in 56 (83.6%) out of the 67 patients studied. The average delay in getting INR results was 1 hour 14 minutes and delay between releasing the PCC from blood bank to infusion was 3 hours. CONCLUSION: A simple three level low fixed dose protocol is cost effective in reversing the majority of patients' anticoagulation. Delay in initiating treatment for the reversal of VKA and adherence to protocols remained problematic.

Von Willebrand's disease and angiodysplasia treated with thalidomide.

A 54-year-old man with type IIB VWD and severe angiodysplasia had such a large blood loss from the bowel that it was difficult to keep up with transfusion requirements. Treatment with factor eight concentrate barely slowed the loss. D.D.A.V.P., Octreotide, and recombinant activated Factor VII, tried separately, were ineffective. The use of Thalidomide at a dose of 150 mg daily has rendered him free from blood loss for the last six months and we suggest would be worth a trial in similar cases.

Audit of correction of high INR in an anticoagulation clinic.

Examination of the ways in which staff in the anticoagulation clinic dealt with high International Normalized Ratio (INR) results, not dosed by the computer programme, revealed an unacceptable variation in dosage change. Our aim has been to produce a protocol for either manual use and/or transfer to the computer, which would safely correct INR above the upper limit of the therapeutic range, 4.5 to a maximum of 8.0 within 7 days. We collected a large number of results (4.095) and arranged them in four INR groups (4.6-5.0, 5.1-6.0, 6.1-7.0 and 7.1-8.0) and three dosage classes (<3, 3-8 and >8 mg) in order to analyse the effects of the regimens used. This has enabled us to construct a protocol partly empirically and partly by use of a graph correlating dosage change with reduction in the INR, which will now be tested in the clinic. This protocol will deal with all INR up to a maximum of 7.0 as we have decided to contact patients with higher results. Putting this protocol onto the computer should reduce manual dosing by 15%.

Myelodysplasia and bone marrow fibrosis treated with calcitriol and venesection.

We report a patient with myelodysplasia and bone marrow fibrosis. We managed him with regular blood transfusion for a period of 16 months. A modest dose of calcitriol (1,25-dihydroxycholecalciferol) 0.75 microg daily for 12 weeks resulted in a gradual but complete response in his haemoglobin level. There were significant bone marrow changes in that the fibrosis has completely disappeared although the marrow cytology remained dysplastic. The normal haemoglobin level persists despite an intensive venesection programme aimed at reducing iron overload. We conclude that calcitriol should be given for at least 12 weeks in patients with myelodysplasia especially if there is a fibrotic element in the bone marrow. The role of venesection in maintaining remission is a speculative.

Audit of anticoagulant therapy and acute hospital admissions.

We conducted an audit on the contribution of failure of control of anticoagulant therapy to acute hospital admissions. Over a period of 3 months there were 1480 acute admissions. One-hundred-and-twelve (7.6%) of these patients were on anticoagulant therapy. One-hundred-and-three of these 112 patients were evaluated, 74 patients had international normalized ratios (INRs) in the therapeutic range, of whom four (5.4%) bled from causes unlikely to be due directly to anticoagulant therapy. Twenty-nine patients were over-anticoagulated. Of these, 17 (59%) were admitted with bleeding symptoms, which may have been a consequence of high INR, while one had a very high INR but no bleeding. Eleven more patients were admitted for reasons unrelated to anticoagulant therapy but were found to have over-therapeutic INRs, which may have influenced their subsequent hospital management. The only clear difference between the bleeding and nonbleeding groups was age. Reasons for over-anticoagulation were poor patient compliance in 31%, influence of other medications in 17, congestive heart failure in 28%, and unknown in 24%. In conclusion, 22/1480 hospital admissions (1.5%) were due to warfarin complications and 16/21 bleeding patients had INRs > 4.5. These are admissions that could potentially be avoided with better anticoagulation control.

Pure red cell aplasia in a patient with chronic granulocytic leukaemia treated with interferon-alpha.

Interferon-alpha has been shown to improve survival in patients with chronic granulocytic leukaemia, therefore it is increasingly becoming part of the standard treatment of this condition. Interferon has a wide variety of side-effects. Pure red cell aplasia has been reported in a few cases of chronic granulocytic leukaemia but this usually heralds the onset of the transformation to the acute phase. This paper reports a possible, and not previously reported, side-effect of interferon-alpha in a patient with chronic granulocytic leukaemia.