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Therapeutic Areas and Products

Hematology

VKA-related bleeding

Disease Background and Prevalence

  • Vitamin K antagonists (VKAs) are widely used for the primary and secondary prevention of venous and arterial thromboembolic events.
  • VKAs, such as warfarin, interfere with the y-carboxylation of the calcium-active binding sites for vitamin K-dependent proteins (including coagulation factors II, VII, IX and X), resulting in the reduction of clotting factors II, VII, IX, X as well as pro-coagulation proteins C and S.
  • The most common adverse reaction of warfarin is hemorrhage, accounting for approximately 29,000 emergency department visits per year.
  • There are up to 10,000 cases of warfarin-associated intracranial hemorrhage (ICH) in the US annually.
  • Patients on warfarin who experience head injury have a 40% higher risk of incurring ICH and a 2-fold higher risk of 30-day in-hospital mortality.
  • Gastrointestinal bleeding (GIB) accounts for 30% to 60% of the annual incidence of major bleeding complications, with up to one-third of GIB patients experiencing the first bleeding episode within 1 month of initiating anticoagulation and about 61% of GI bleeds occurring within the first year after initiating anticoagulation.

Management

  • Warfarin reversal strategies include: fresh frozen plasma (FFP), vitamin K, prothrombin complex concentrates (PCC): (3 Factor PCC, non-activated 4 Factor PCC and activated 4F Factor PCC)
  • Kcentra®, Prothrombin Complex Concentrate (Human), is the only FDA-approved 4F-PCC for warfarin-related reversal in the setting of acute major bleeding and need for urgent surgery or procedure in adult patients.

4 connected green hexagons with text about factors to consider when selecting reversal agent

Monitoring

  • The prothrombin time (PT) test or International Normalized Ratio (INR), which is a standardized expression of the PT, is most commonly used to monitor VKA therapy.
    • The most common target INR is 2.0–3.0 for patients on warfarin; the INR range can vary depending on the indication when on VKA therapy.
  • In two pivotal clinical trials, the INR reduction target for VKA reversal was ≤1.3 at 0.5 hours after end of infusion

Treatment Guidelines

1. DeAngelo J et al. Am J Ther. 2018;25(3):e326-e332. 2. American Association of Blood Banks. Circular of information for the use of human blood and blood components. Bethesda, MD; November 2017. 3. National Patient Safety Goal for anticoagulant therapy. The Joint Commission website. Accessed June 4, 2020. https://www.jointcommission.org/-/media/tjc/newsletters/r3_19_anticoagulant_therapy_final2pdf.pdf. 4. Frumkin K. Ann Emerg Med. 2013;62:616-626. 5. Cleary JP et al. Ann Transplant. 2016;21:531-537. 5. Frontera JA et al. Neurocrit Care. 2016;24:6-46. 6. Holbrook A et al. Chest. 2012;141:e152S-e184S. 7. Acosta RD et al. Gastrointest Endosc. 2016;83:3-16. 8. Tomaselli GF et al. J Am Coll Cardiol. 2017;70:3042-3067. 9. Witt DM et al. Blood Adv. 2018;2:3257-3291. 10. Baugh CW et al. Ann Emerg Med. 2019;9:1-16. 11. American College of Surgeons. Advanced Trauma Life Support (ATLS) Student Course Manual. 10th ed. Chicago, IL: American College of Surgeons; 2018

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