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1.
J Thromb Thrombolysis ; 47(2): 263-271, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30443817

RESUMO

BACKGROUND: Four-factor PCC is the recommended standard of care for acute warfarin reversal but optimal dosing is unknown. We aim to show that a low-dose strategy is often adequate and may reduce the risk of thromboembolic events when compared to manufacturer-recommended dosing. METHODS: A weight-based dosing strategy of 15-25 units/kg was established as the institutional standard of care in May 2015. This retrospective, before-and-after cohort analysis included patients receiving 4F-PCC according to a manufacturer-recommended (n = 122) or a low-dose (n = 83) strategy. The primary efficacy outcome was a combination of INR reversal on first check and hemostatic efficacy at 24 h. RESULTS: Demographics, indications for warfarin, and presenting INR values were similar between the two groups. Patients in the manufacturer-recommended dose group received significantly more 4F-PCC than the low dose group (2110 units vs. 1530 units). More patients in the manufacturer-recommended dose group achieved the primary endpoint (75.4% vs. 61.4%), with more patients achieving the target INR on recheck in the manufacturer-recommended dose group (95.9% vs. 84.3%) and no difference in hemostatic efficacy between groups (79.5% vs. 74.7%). There was no difference in thromboembolic events at 72 h (4.1% vs. 1.2%) or at 30 days (8.2% vs. 4.8%). Significantly more patients in the manufacturer-recommended dose group died or were transferred to hospice care during hospitalization (21.3% vs. 9.6%). CONCLUSION: Utilization of a low-dose 4F-PCC strategy resulted in fewer patients achieving target INR reversal, but no difference in hemostatic efficacy, thromboembolic events, or survival.


Assuntos
Anticoagulantes , Fatores de Coagulação Sanguínea/administração & dosagem , Hemorragia/tratamento farmacológico , Hemostasia/efeitos dos fármacos , Antagonistas de Heparina/administração & dosagem , Varfarina/antagonistas & inibidores , Idoso , Idoso de 80 Anos ou mais , Anticoagulantes/administração & dosagem , Anticoagulantes/efeitos adversos , Fatores de Coagulação Sanguínea/efeitos adversos , Peso Corporal , Cálculos da Dosagem de Medicamento , Monitoramento de Medicamentos/métodos , Feminino , Hemorragia/induzido quimicamente , Hemorragia/diagnóstico , Antagonistas de Heparina/efeitos adversos , Humanos , Coeficiente Internacional Normatizado , Masculino , Modelos Biológicos , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Resultado do Tratamento , Varfarina/administração & dosagem , Varfarina/efeitos adversos
2.
Can J Surg ; 62(1): 14-19, 2019 02 01.
Artigo em Inglês | MEDLINE | ID: mdl-30265643

RESUMO

BACKGROUND: Patients with hip fracture who present anticoagulated with warfarin often require reversal of anticoagulation for safe hip fracture surgery. Vitamin K is typically administered for this, but requires 24-48 hours for maximal effect. These patients have an increased delay to surgery and increased mortality. Octaplex is a prothrombin complex concentrate (PCC) that reverses warfarin anticoagulation in less than an hour. This study assesses the effectiveness and safety of Octaplex for reversal of warfarin anticoagulation for hip fracture surgery. METHODS: We reviewed the medical records of all patients with hip fracture in Calgary who received Octaplex between 2009 and 2015. Timing of admission, Octaplex administration and hip fracture surgery were recorded. Mortality and cardiac, thrombotic and orthopedic complications were assessed. RESULTS: Median time from Octaplex administration to an international normalized ratio of 1.4 or lower was 1.1 hours. The median time from admission to surgery was 22 hours. Thirty-day mortality was 15.2%, with 4 cases of cardiac arrest and 1 respiratory arrest. Patients who received both Octaplex and fresh frozen plasma (FFP) had a lower rate of 30-day survival than those who received only Octaplex (95.7% v. 60.0%, p = 0.002). CONCLUSION: There were significant rates of cardiac events and 30-day mortality among patients who received Octaplex, but this is unsurprising in this population with multiple medical comorbidities. We caution against administrering both FFP and a PCC in patients for warfarin reversal. Octaplex is effective for rapidly reversing warfarin anticoagulation and reducing delays to hip fracture surgery. Further study comparing Octaplex to reversal using only vitamin K is required.


Assuntos
Anticoagulantes , Transtornos da Coagulação Sanguínea/tratamento farmacológico , Fatores de Coagulação Sanguínea/administração & dosagem , Fraturas do Quadril/cirurgia , Varfarina/antagonistas & inibidores , Idoso , Idoso de 80 Anos ou mais , Coagulação Sanguínea/efeitos dos fármacos , Transtornos da Coagulação Sanguínea/induzido quimicamente , Fatores de Coagulação Sanguínea/efeitos adversos , Feminino , Humanos , Coeficiente Internacional Normatizado , Masculino , Estudos Retrospectivos , Fatores de Tempo , Tempo para o Tratamento , Resultado do Tratamento
3.
J Thromb Thrombolysis ; 46(2): 180-185, 2018 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-29785470

RESUMO

Continuous flow left ventricular assist devices (CF-LVAD) require therapeutic anticoagulation which is often interrupted for procedures or bleeding. Prior to the availability of four factor prothrombin complex concentrate (4F-PCC) in the United States, warfarin was held and its effects reversed by vitamin K or fresh frozen plasma. We evaluated the use of 4F-PCC for temporary warfarin reversal in patients with CF-LVADs and assessed outcomes. This analysis is a retrospective study of CF-LVAD patients who received 4F-PCC for warfarin reversal in the setting of bleeding or need for urgent or elective procedures. Primary outcome assessments included feasibility of administration in elective versus emergent situations, safety measured as incidence of thrombotic events, and change in INR after administration. In total, 37 CF-LVAD patients received 49 4F-PCC administrations. The average 4F-PCC dose was 1842 units (range 518-4292 units), or 22 units/kg (range 5.8-58 units/kg). 4F-PCC significantly decreased the mean INR from 2.9 to 1.7 (p < 0.0001) in 47 of 49 administrations; two patients did not have post infusion INR testing. No cases of new confirmed or suspected pump thrombosis, stroke, venous thromboembolism, arterial thrombosis, or myocardial infarction were observed within 30 days of administration of 4F-PCC. 4F-PCC administration for temporary warfarin reversal was demonstrated to be feasible, effective, and, safe in CF-LVAD patients and judged to be 96% effective in patients for whom data were available. We observed no thrombotic events attributed to use of 4F-PCC.


Assuntos
Fatores de Coagulação Sanguínea/uso terapêutico , Coração Auxiliar , Varfarina/antagonistas & inibidores , Idoso , Idoso de 80 Anos ou mais , Fatores de Coagulação Sanguínea/farmacologia , Interações Medicamentosas , Ventrículos do Coração/cirurgia , Humanos , Coeficiente Internacional Normatizado , Pessoa de Meia-Idade , Resultado do Tratamento , Varfarina/uso terapêutico
4.
J Surg Res ; 223: 183-187, 2018 03.
Artigo em Inglês | MEDLINE | ID: mdl-29433872

RESUMO

BACKGROUND: Patients with traumatic intracranial hemorrhage (TIH) anticoagulated with warfarin are at an increased risk of mortality. Fresh frozen plasma (FFP) and vitamin K have been the standard treatment for warfarin reversal; however, guidelines now recommend the use of prothrombin complex concentrate (PCC) for warfarin reversal in patients with life-threatening bleeding. Our protocol uses one vial (∼1000 units) of activated PCC (aPCC) for warfarin reversal, regardless of the weight or presenting international normalized ratio (INR). The purpose of this study was to determine the safety and efficacy of using fixed, low-dose aPCC for warfarin reversal in patients with TIH. METHODS: This was a retrospective chart review that included patients with an Abbreviated Injury Scale Head score of ≥3, TIH, and initial INR ≥ 1.5 on warfarin. Patients aged <18 years and those with no repeat INR were excluded. The primary outcome was to compare the percentage of patients with INR ≤ 1.4 after receiving aPCC versus FFP within 24 hours. RESULTS: Eighty-nine patients were in the FFP group and 31 patients in the aPCC group. The INR was reversed more effectively in the aPCC group compared with the FFP group (90.3% versus 69.7%, P = 0.029). The median time (hours) to reversal was also significantly shorter in the aPCC group compared with the FFP group (3.75 versus 6.75, P = 0.003). However, there was no difference in mortality (35.5% aPCC versus 22.2% control, P = 0.162) or incidences of thrombosis. CONCLUSION: Fixed, low-dose aPCC is safe and more effective at reversing the effects of warfarin than FFP in patients with TIH.


Assuntos
Fatores de Coagulação Sanguínea/uso terapêutico , Hemorragia Intracraniana Traumática/tratamento farmacológico , Varfarina/antagonistas & inibidores , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Coeficiente Internacional Normatizado , Masculino , Estudos Retrospectivos
5.
Neurosurgery ; 82(6): 877-886, 2018 06 01.
Artigo em Inglês | MEDLINE | ID: mdl-29106685

RESUMO

BACKGROUND: Reversal of therapeutic anticoagulation prior to emergency neurosurgical procedures is required in the setting of intracranial hemorrhage. Multifactor prothrombin complex concentrate (PCC) promises rapid efficacy but may increase the probability of thrombotic complications compared to fresh frozen plasma (FFP). OBJECTIVE: To compare the rate of thrombotic complications in patients treated with PCC or FFP to reverse therapeutic anticoagulation prior to emergency neurosurgical procedures in the setting of intracranial hemorrhage at a level I trauma center. METHODS: Sixty-three consecutive patients on warfarin therapy presenting with intracranial hemorrhage who received anticoagulation reversal prior to emergency neurosurgical procedures were retrospectively identified between 2007 and 2016. They were divided into 2 cohorts based on reversal agent, either PCC (n = 28) or FFP (n = 35). The thrombotic complications rates within 72 h of reversal were compared using the χ2 test. A multivariate propensity score matching analysis was used to limit the threat to interval validity from selection bias arising from differences in demographics, laboratory values, history, and clinical status. RESULTS: Thrombotic complications were uncommon in this neurosurgical population, occurring in 1.59% (1/63) of treated patients. There was no significant difference in the thrombotic complication rate between groups, 3.57% (1/28; PCC group) vs 0% (0/35; FFP group). Propensity score matching analysis validated this finding after controlling for any selection bias. CONCLUSION: In this limited sample, thrombotic complication rates were similar between use of PCC and FFP for anticoagulation reversal in the management of intracranial hemorrhage prior to emergency neurosurgical procedures.


Assuntos
Fatores de Coagulação Sanguínea/uso terapêutico , Hemorragias Intracranianas/cirurgia , Plasma , Tromboembolia/epidemiologia , Varfarina/antagonistas & inibidores , Idoso , Anticoagulantes/uso terapêutico , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Procedimentos Neurocirúrgicos/métodos , Pontuação de Propensão , Estudos Retrospectivos , Centros de Traumatologia
6.
Nurse Pract ; 42(11): 8-14, 2017 Nov 16.
Artigo em Inglês | MEDLINE | ID: mdl-28957948

RESUMO

For more than half a century, warfarin, a vitamin K antagonist, has been the anticoagulant of choice. However, direct oral anticoagulants are rapidly gaining in popularity, which poses the need for efficacious reversal agents. This review article summarizes the strategies and agents used to reverse oral anticoagulants.


Assuntos
Anticoagulantes/administração & dosagem , Dabigatrana/antagonistas & inibidores , Pirazóis/antagonistas & inibidores , Piridinas/antagonistas & inibidores , Piridonas/antagonistas & inibidores , Rivaroxabana/antagonistas & inibidores , Tiazóis/antagonistas & inibidores , Varfarina/antagonistas & inibidores , Administração Oral , Ensaios Clínicos Fase III como Assunto , Humanos
8.
Vox Sang ; 112(6): 595-597, 2017 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-28635130

RESUMO

For emergent warfarin reversal, four-factor prothrombin complex concentrates (4FPCCs) are recommended by many international guidelines. We surveyed international clinical sites including members of the Biomedical Excellence for Safer Transfusion (BEST) Collaborative. Most sites have emergent warfarin reversal protocols (53% use PCC, 25% use PCC+ plasma and 2% use plasma alone); however, variation between adjusted dosing and fixed dosing was observed.


Assuntos
Anticoagulantes , Fatores de Coagulação Sanguínea/uso terapêutico , Protocolos Clínicos , Hospitais , Varfarina/antagonistas & inibidores , Humanos , Plasma , Inquéritos e Questionários
9.
Med Klin Intensivmed Notfmed ; 112(2): 99-104, 2017 Mar.
Artigo em Alemão | MEDLINE | ID: mdl-28144725

RESUMO

The non-vitamin K antagonists (NOAC) are an integral component of our antithrombotic prevention and therapy. For four of the NOAC, their non-inferiority or even superiority versus vitamin K antagonists (VKA) has been proven. Thus, the management of special patient cohorts or the management of active bleeding complications is a focus of current discussion.In addition to prospective trials, numerous retrospective analyses of health insurers or public health provider data have been analyzed and published as "real life" or "real-world evidence" data. In almost all data sets the results of the NOAC approval trials were confirmed, demonstrating their non-inferiority or even superiority versus VKA. Attempts to compare the various NOAC with each other must be viewed critically since the real-world evidence (RWE) analysis provides very divergent results depending on the cohorts analyzed. Thus, a substantial prescriber-bias must be taken into account and never be excluded.In order to improve the management of bleeding complications, NOAC antidotes were developed. While the factors Xa antidote, andexanet alpha, a modified coagulation factor deleted of an intrinsic activity, will not be available before 2018, the dabigatran antidote idarucizumab is already in clinical use. Idarucizumab, a monoclonal antibody fragment directed against dabigatran, is able to completely antagonize the effect of dabigatran within minutes. Therefore, the drug has the potential to terminate life-threatening bleeding complications earlier and make emergency surgical or interventional procedures possible without an elevated bleeding risk.


Assuntos
Anticorpos Monoclonais Humanizados/efeitos adversos , Anticoagulantes/efeitos adversos , Anticoagulantes/uso terapêutico , Antídotos/uso terapêutico , Hemorragia/induzido quimicamente , Hemorragia/tratamento farmacológico , Acidente Vascular Cerebral/sangue , Acidente Vascular Cerebral/tratamento farmacológico , Tromboembolia/prevenção & controle , Idoso , Anticorpos Monoclonais Humanizados/uso terapêutico , Antídotos/efeitos adversos , Dabigatrana/efeitos adversos , Dabigatrana/antagonistas & inibidores , Dabigatrana/uso terapêutico , Fator Xa/efeitos adversos , Fator Xa/uso terapêutico , Inibidores do Fator Xa/efeitos adversos , Inibidores do Fator Xa/uso terapêutico , Feminino , Humanos , Masculino , Pirazóis/efeitos adversos , Pirazóis/antagonistas & inibidores , Piridonas/efeitos adversos , Piridonas/antagonistas & inibidores , Proteínas Recombinantes/efeitos adversos , Proteínas Recombinantes/uso terapêutico , Rivaroxabana/efeitos adversos , Rivaroxabana/antagonistas & inibidores , Tromboembolia/sangue , Vitamina K/antagonistas & inibidores , Varfarina/efeitos adversos , Varfarina/antagonistas & inibidores
10.
J Emerg Med ; 52(1): 1-7.e1, 2017 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-27793500

RESUMO

BACKGROUND: Most comparisons of bleeding patients who are taking warfarin or a non-vitamin K oral anticoagulant (NOAC) have been limited to admitted patients and major bleeding events in well-controlled, clinical trial settings. OBJECTIVES: We describe the clinical characteristics, interventions, and outcomes in patients who are taking warfarin or a NOAC who presented to the emergency department (ED) with any bleeding event. METHODS: We conducted a structured, retrospective, observational study of nonvalvular atrial fibrillation, pulmonary embolism, or deep vein thrombosis warfarin- or NOAC-treated patients presenting with any bleeding event to a large, academic ED between January 2012 and March 2015. We used descriptive statistics to summarize baseline characteristics, treatments, and outcomes and performed subgroup analyses based on the type of anticoagulant and site of bleeding. RESULTS: The electronic search yielded 95 cases of patients taking a NOAC (i.e., dabigatran [33], rivaroxaban [32], or abixaban [30]) and 342 patients taking warfarin. Reversal agents were rarely used in all anticoagulant groups. Case fatality rates were similar among warfarin- and NOAC-treated patients for gastrointestinal bleeding (7% vs. 7%) and intracranial hemorrhage (18% vs. 4%), respectively. After adjustment for other factors, only intracranial hemorrhage (odds ratio 4.4; 95% confidence interval 1.4-13.3) was associated with mortality. CONCLUSIONS: Despite the rare use of reversal strategies, mortality was low and outcomes were comparable among patients with bleeding events presenting to the ED while taking a NOAC compared with warfarin.


Assuntos
Hemorragia/terapia , Avaliação de Resultados da Assistência ao Paciente , Varfarina/efeitos adversos , Administração Oral , Idoso , Idoso de 80 Anos ou mais , Anticoagulantes/farmacologia , Anticoagulantes/uso terapêutico , Serviço Hospitalar de Emergência/organização & administração , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Hemorragia/mortalidade , Humanos , Masculino , Estudos Retrospectivos , Vitamina K/farmacologia , Vitamina K/uso terapêutico , Varfarina/antagonistas & inibidores
11.
Thromb Haemost ; 116(5): 879-890, 2016 Oct 28.
Artigo em Inglês | MEDLINE | ID: mdl-27488143

RESUMO

Urgent reversal of warfarin is required for patients who experience major bleeding or require urgent surgery. Treatment options include the combination of vitamin K and coagulation factor replacement with either prothrombin complex concentrate (PCC) or fresh frozen plasma (FFP). However, the optimal reversal strategy is unclear based on clinically relevant outcomes. We searched in MEDLINE, EMBASE and Cochrane library to December 2015. Thirteen studies (5 randomised studies and 8 observational studies) were included. PCC use was associated with a significant reduction in all-cause mortality compared to FFP (OR= 0.56, 95 % CI; 0.37-0.84, p=0.006). A higher proportion of patients receiving PCC achieved haemostasis compared to those receiving FFP, but this was not statistically significant (OR 2.00, 95 % CI; 0.85-4.68). PCC use was more likely to achieve normalisation of international normalised ratio (INR) (OR 10.80, 95 % CI; 6.12-19.07) and resulted in a shorter time to INR correction (mean difference -6.50 hours, 95 %CI; -9.75 to -3.24). Red blood cell transfusion was not statistically different between the two groups (OR 0.88, 95 % CI: 0.53-1.43). Patients receiving PCC had a lower risk of post-transfusion volume overload compared to FFP (OR 0.27, 95 % CI; 0.13-0.58). There was no statistically significant difference in the risk of thromboembolism following administration of PCC or FFP (OR 0.91, 95 % CI; 0.44-1.89). In conclusion, as compared to FFP, the use of PCC for warfarin reversal was associated with a significant reduction in all-cause mortality, more rapid INR reduction, and less volume overload without an increased risk of thromboembolic events.


Assuntos
Fatores de Coagulação Sanguínea/uso terapêutico , Plasma , Varfarina/antagonistas & inibidores , Anticoagulantes , Hemorragia/tratamento farmacológico , Humanos , Coeficiente Internacional Normatizado , Estudos Observacionais como Assunto , Ensaios Clínicos Controlados Aleatórios como Assunto
12.
Dtsch Med Wochenschr ; 141(11): 777-80, 2016 Jun.
Artigo em Alemão | MEDLINE | ID: mdl-27254626

RESUMO

The phase III non-vitamin K dependent oral anticoagulants (NOAC) studies and recently published real world data on the use of dabigatran and rivaroxaban have shown that the bleeding profile in particular of intracranial and other life-threatening bleeding of NOAC is more favourable than that of warfarin. In case of a bleeding complication in a patient treated with a NOAC the recently updated EHRA practical guide offers management strategies. Idarucizumab, the specific antidot for dabigatran is approved to reverse the anticoagulant effect of dabigatran-treated patients who have serious bleeding and require an urgent procedure. Andexanet alfa, a specific antidot for direct and indirect factor Xa-inhibitors will be available in the future. The frequency of thrombocytopenia in ICU patients is high whereas the heparin induced thrombocytopenia (HIT) only counts for a small minority of patients with thrombocytopenia. To avoid an overdiagnosis of HIT a reliable and complete clinical and laboratory workup has to be performed. New immunoassays have been developed to provide results within a short period of time. These tests appear to have improved diagnostic accuracy compared with ELISAs in patients with suspected HIT and may reduce misdiagnosis and overtreatment. Acquired haemophilia (AH) is a rare and often life threatening bleeding disorder caused by autoantibodies against factor VIII. Susoctocog alfa is a B-domain deleted recombinant factor VIII porcine sequence that has recently been approved to treat severe bleeding in patients with AH. Susoctocog alfa offers the ability to effectively titrate and monitor dosing based on factor VIII activity levels.


Assuntos
Anticoagulantes/efeitos adversos , Anticoagulantes/uso terapêutico , Hemorragia/induzido quimicamente , Hemorragia/tratamento farmacológico , Unidades de Terapia Intensiva , Trombose/tratamento farmacológico , Dabigatrana/efeitos adversos , Dabigatrana/antagonistas & inibidores , Dabigatrana/uso terapêutico , Hemofilia A/induzido quimicamente , Hemofilia A/diagnóstico , Hemofilia A/tratamento farmacológico , Heparina/efeitos adversos , Heparina/uso terapêutico , Humanos , Rivaroxabana/efeitos adversos , Rivaroxabana/antagonistas & inibidores , Rivaroxabana/uso terapêutico , Trombocitopenia/induzido quimicamente , Trombocitopenia/diagnóstico , Trombocitopenia/tratamento farmacológico , Trombose/sangue , Varfarina/efeitos adversos , Varfarina/antagonistas & inibidores , Varfarina/uso terapêutico
13.
Anaesth Intensive Care ; 43(6): 712-8, 2015 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-26603795

RESUMO

Periprocedural management of patients on long-term warfarin therapy remains a common and important clinical issue, with little high-quality data to guide this complex process. The current accepted practice is cessation of warfarin five days preoperatively, but this is not without risk and can be complicated, particularly if bridging is required. An alternative method utilising low-dose intravenous vitamin K the day before surgery has been shown previously to be efficacious, safe and convenient in an elective surgical population receiving chronic warfarin therapy. The efficacy and utility of this 'fast-track' warfarin reversal protocol in surgical patients with cancer, who were at high risk of both thromboembolism and bleeding was investigated in a prospective, single-arm study at a dedicated cancer centre. Seventy-one patients underwent 82 episodes of fast-track warfarin reversal (3 mg intravenous vitamin K 18 to 24 hours before surgery). No patient suffered an adverse reaction to intravenous vitamin K, all but one achieved an International Normalized Ratio =1.5 on the day of surgery, and no surgery was deferred. Assays of vitamin K-dependent factor levels pre- and post-vitamin K demonstrated restoration of functional activity to within an acceptable range for surgical haemostasis. While this alternative method requires further validation in a larger prospective randomised study, we have now extended our use of fast-track warfarin reversal using vitamin K to patients with cancer, on the basis of our experience of its safety, convenience, reliability and efficacy.


Assuntos
Anticoagulantes/farmacologia , Neoplasias/cirurgia , Vitamina K/uso terapêutico , Varfarina/antagonistas & inibidores , Adulto , Idoso , Idoso de 80 Anos ou mais , Procedimentos Cirúrgicos Eletivos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Vitamina K/efeitos adversos
15.
Drugs R D ; 15(1): 155-62, 2015 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-25749804

RESUMO

BACKGROUND: Hip fractures require operation within 36-48 h, and they are most common in the elderly. A high International Normalized Ratio should be corrected before surgery. In the current study, we analyzed the budget impact of various warfarin reversal approaches. METHODS: Four reversal strategies were chosen for the budget impact analysis: the temporary withholding of warfarin, administration of vitamin K, fresh frozen plasma (FFP), and a four-factor prothrombin complex concentrate (PCC). RESULTS: We estimated that, annually, 410 hip fracture patients potentially require warfarin reversal in Finland. The least costly treatment was vitamin K, which accounted for €289,000 in direct healthcare costs, and the most costly treatment option was warfarin cessation, which accounted for €1,157,000. In the budget impact analysis, vitamin K, PCC and FFP would be cost-saving to healthcare compared with the current treatment mix. CONCLUSION: The various warfarin reversal strategies have different onset times, which may substantially impact the subsequent healthcare costs.


Assuntos
Anticoagulantes/efeitos adversos , Custos de Cuidados de Saúde , Fraturas do Quadril/cirurgia , Varfarina/antagonistas & inibidores , Idoso , Fatores de Coagulação Sanguínea/administração & dosagem , Fatores de Coagulação Sanguínea/economia , Orçamentos , Feminino , Finlândia , Humanos , Coeficiente Internacional Normatizado , Masculino , Plasma , Fatores de Tempo , Vitamina K/administração & dosagem , Vitamina K/economia , Varfarina/efeitos adversos
16.
Kyobu Geka ; 67(6): 505-7, 2014 Jun.
Artigo em Japonês | MEDLINE | ID: mdl-24917411

RESUMO

A 55-year-old gentleman diagnosed with severe aortic insufficiency and annuloaortic ectasia underwent modified Bentall procedure using mechanical valve. Anticoagulation therapy with warfarin was introduced after surgery, but sufficient anticoagulation effect was not achieved with a large amount of dosage. After discontinuing the use of the Clostridium butyricum preparation on postoperative day 29, sufficient anticoagulationt effect was obtained within several days. Clostridium butyricum might change the vitamin K production in the intestinal bacterial flora and attenuated the anticoagulation effect of warfarin.


Assuntos
Anticoagulantes/farmacologia , Produtos Biológicos/efeitos adversos , Clostridium butyricum , Varfarina/antagonistas & inibidores , Insuficiência da Valva Aórtica/cirurgia , Humanos , Masculino , Pessoa de Meia-Idade , Período Pós-Operatório
17.
J Clin Neurosci ; 21(11): 1881-4, 2014 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-24953825

RESUMO

Warfarin-associated intracranial hemorrhage is associated with a high mortality rate. Ongoing coagulopathy increases the likelihood of hematoma expansion and can result in catastrophic hemorrhage if surgery is performed without reversal. The current standard of care for emergency reversal of warfarin is with fresh frozen plasma (FFP). In April 2013, the USA Food and Drug Administration approved a new reversal agent, 4-factor prothrombin complex concentrate (PCC), which has the potential to more rapidly correct coagulopathy. We sought to determine the feasibility and outcomes of using PCC for neurosurgical patients. A prospective, observational study of all patients undergoing coagulopathy reversal for intracranial hemorrhage from April 2013 to December 2013 at a single, tertiary care center was undertaken. Thirty three patients underwent emergent reversal of coagulopathy using either FFP or PCC at the discretion of the treating physician. Intracranial hemorrhage included subdural hematoma, intraparenchymal hematoma, and subarachnoid hemorrhage. FFP was used in 28 patients and PCC was used in five patients. International normalized ratio at presentation was similar between groups (FFP 2.9, PCC 3.1, p=0.89). The time to reversal was significantly shorter in the PCC group (FFP 256 minutes, PCC 65 minutes, p<0.05). When operations were performed, the time delay to perform operations was also significantly shorter in the PCC group (FFP 307 minutes, PCC 159 minutes, p<0.05). In this preliminary experience, PCC appears to provide a rapid reversal of coagulopathy. Normalization of coagulation parameters may prevent further intracranial hematoma expansion and facilitate rapid surgical evacuation, thereby improving neurological outcomes.


Assuntos
Antídotos/uso terapêutico , Fatores de Coagulação Sanguínea/uso terapêutico , Lesões Encefálicas/tratamento farmacológico , Hemorragias Intracranianas/tratamento farmacológico , Varfarina/efeitos adversos , Anticoagulantes/uso terapêutico , Antídotos/farmacologia , Fatores de Coagulação Sanguínea/farmacologia , Hemorragia/induzido quimicamente , Hemorragia/tratamento farmacológico , Humanos , Coeficiente Internacional Normatizado , Hemorragias Intracranianas/induzido quimicamente , Plasma , Guias de Prática Clínica como Assunto , Estudos Prospectivos , Ensaios Clínicos Controlados Aleatórios como Assunto , Doenças da Coluna Vertebral/tratamento farmacológico , Hemorragia Subaracnóidea/tratamento farmacológico , Centros de Atenção Terciária , Varfarina/antagonistas & inibidores , Varfarina/uso terapêutico
19.
J Med Toxicol ; 10(2): 156-64, 2014 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-24488527

RESUMO

Warfarin, a vitamin K antagonist, is widely used for the prophylaxis and treatment of thromboembolic disease. While guidelines exist for management of a supratherapeutic international normalized ratio following therapeutic warfarin use, these guidelines are not designed for management of the acute warfarin overdose. There is a paucity of literature describing the latter. The primary objective of this manuscript is to characterize the coagulopathy and describe the bleeding events that occur after a warfarin overdose. A secondary goal is to describe the amount of vitamin K administered to patients presenting with warfarin overdoses. A retrospective chart review of patients admitted with an acute warfarin overdose at two tertiary care medical centers in the USA was conducted. Clinical characteristics were abstracted, and bleeding categories (major, minor, trivial) were defined a priori. Twenty-three patients were admitted during the time period; males accounted for 15/23 (62.5 %) subjects. The median (interquartile range (IQR)) age was 43 (32-48.5) years. Seventeen subjects received vitamin K, with a median (IQR) dose of 15 (10-50) mg. The maximal total amount of vitamin K administered to a single patient during the index hospitalization was 110 mg. Three bleeding events occurred; one classified as major, and two as minor. All patients made a full recovery. In this case series of acute warfarin overdose, nearly all patients developed a coagulopathy, and nearly three-quarters of patients received vitamin K. Bleeding events occurred in a minority of patients.


Assuntos
Anticoagulantes/envenenamento , Overdose de Drogas/terapia , Varfarina/envenenamento , Acidentes Domésticos , Adulto , Anticoagulantes/química , Antídotos/administração & dosagem , Antídotos/uso terapêutico , Comportamento Infantil , Pré-Escolar , Terapia Combinada , Relação Dose-Resposta a Droga , Overdose de Drogas/tratamento farmacológico , Overdose de Drogas/fisiopatologia , Feminino , Hemorragia/etiologia , Hemorragia/prevenção & controle , Humanos , Masculino , Pessoa de Meia-Idade , Encaminhamento e Consulta , Estudos Retrospectivos , Centros de Atenção Terciária , Resultado do Tratamento , Estados Unidos , Vitamina K/administração & dosagem , Vitamina K/uso terapêutico , Varfarina/antagonistas & inibidores
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