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Title: | An update of consensus guidelines for warfarin reversal. | Authors: | Chunilal S.D.;Tran H. ;Harper P.L.;Tran H.A.;Gallus A.S.;Wood E.M. | Institution: | (Tran) Clinical Haematology, Alfred Hospital, Melbourne, VIC, Australia (Tran, Chunilal, Wood) Haematology, Monash Medical Centre, Melbourne, VIC, Australia (Harper) Clinical Haematology, Palmerston North Hospital, Palmerston North, New Zealand (Tran) Haematology, Dorevitch Pathology, Melbourne, VIC, Australia (Wood) Diagnostic Haematology, Royal Melbourne Hospital, Melbourne, VIC, Australia (Wood) Monash University, Melbourne, VIC, Australia (Gallus) Haematology, SA, Pathology at Flinders, Medical Centre, Adelaide, SA, Australia (Gallus) Flinders University, Adelaide, SA, Australia | Issue Date: | 26-Mar-2013 | Copyright year: | 2013 | Publisher: | Australasian Medical Publishing Co. Ltd (E-mail: ampco@ampco.com.au) | Place of publication: | Australia | Publication information: | Medical Journal of Australia. 198 (4) (pp 1-7), 2013. Date of Publication: March 2013. | Journal: | Medical Journal of Australia | Abstract: | Despite the associated bleeding risk, warfarin is the most commonly prescribed anticoagulant in Australia and New Zealand. Warfarin use will likely continue for anticoagulation indications for which novel agents have not been evaluated and among patients who are already stabilised on it or have severe renal impairment. Strategies to manage over-warfarinisation and warfarin during invasive procedures can reduce the risk of haemorrhage. For most warfarin indications, the target international normalised ratio (INR) is 2.0-3.0 (venous thromboembolism and single mechanical heart valve excluding mitral). For mechanical mitral valve or combined mitral and aortic valves, the target INR is 2.5-3.5. Risk factors for bleeding with warfarin use include increasing age, history of bleeding and specific comorbidities. For patients with elevated INR (4.5-10.0), no bleeding and no high risk of bleeding, withholding warfarin with careful subsequent monitoring seems safe. Vitamin K1 can be given to reverse the anticoagulant effect of warfarin. When oral vitamin K1 is used for this purpose, the injectable formulation, which can be given orally or intravenously, is preferred. For immediate reversal, prothrombin complex concentrates (PCC) are preferred over fresh frozen plasma (FFP). Prothrombinex-VF is the only PCC routinely used for warfarin reversal in Australia and New Zealand. It contains factors II, IX, X and low levels of factor VII. FFP is not routinely needed in combination with Prothrombinex-VF. FFP can be used when Prothrombinex-VF is unavailable. Vitamin K1 is essential for sustaining the reversal achieved by PCC or FFP. Surgery can be conducted with minimal increased risk of bleeding if INR <=1.5. For minor procedures where bleeding risk is low, warfarin may not need to be interrupted. If necessary, warfarin can be withheld for 5 days before surgery, or intravenous vitamin K1 can be given the night before surgery. Prothrombinex-VF use for warfarin reversal should be restricted to emergency settings. Perioperative management of anticoagulant therapy requires an evaluation of the risk of thrombosis if warfarin is temporarily stopped, relative to the risk of bleeding if it is continued or modified. | DOI: | http://monash.idm.oclc.org/login?url=http://dx.doi.org/10.5694/mja12.10614 | PubMed URL: | 23451962 [http://www.ncbi.nlm.nih.gov/pubmed/?term=23451962] | ISSN: | 0025-729X | URI: | https://repository.monashhealth.org/monashhealthjspui/handle/1/42538 | Type: | Article | Subjects: | low drug dose mitral valve replacement postoperative care preoperative treatment primary prevention risk reduction secondary prevention thromboembolism/dt [Drug Therapy] thromboembolism/pc [Prevention] thrombosis prevention venous thromboembolism/dt [Drug Therapy] fresh frozen plasma/cb [Drug Combination] fresh frozen plasma/cm [Drug Comparison] fresh frozen plasma/dt [Drug Therapy] heparin/dt [Drug Therapy] low molecular weight heparin/dt [Drug Therapy] prothrombin complex/cb [Drug Combination] prothrombin complex/cm [Drug Comparison] prothrombin complex/dt [Drug Therapy] prothrombin complex/iv [Intravenous Drug Administration] prothrombin complex/pk [Pharmacokinetics] vitamin K group/dt [Drug Therapy] vitamin K group/iv [Intravenous Drug Administration] vitamin K group/po [Oral Drug Administration] *warfarin/ae [Adverse Drug Reaction] *warfarin/dt [Drug Therapy] *warfarin/iv [Intravenous Drug Administration] *warfarin/po [Oral Drug Administration] risk assessment anticoagulant therapy aorta valve replacement article bleeding/dt [Drug Therapy] bleeding/si [Side Effect] blood clotting disorder/si [Side Effect] *consensus development continuous infusion drug half life drug indication drug safety emergency care heart atrium fibrillation/dt [Drug Therapy] heart atrium fibrillation/pc [Prevention] human international normalized ratio invasive procedure long term care heart atrium fibrillation / drug therapy / prevention human international normalized ratio invasive procedure long term care low drug dose mitral valve replacement postoperative care preoperative treatment primary prevention risk assessment article secondary prevention thromboembolism / drug therapy / prevention thrombosis prevention venous thromboembolism / drug therapy aorta valve replacement anticoagulant therapy risk reduction bleeding / drug therapy / side effect blood clotting disorder / side effect *consensus development continuous infusion drug half life drug indication drug safety emergency care |
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