CASE REPORTS Prothrombin complex concentrate
ar Layar
Use of low-dose prothrombin complex concentrate before lumbar puncture Jared J. Butler
I
n April 2013, the Food and Drug Administration approved the first four-factor prothrombin complex concentrate (PCC) (Kcentra, CSL Behring) available in the United States. This product contains coagulation factors II, VII, IX, and X and proteins C and S at variable concentrations. Indications for PCC include urgent reversal of coagulation deficiency induced by vitamin K antagonists in adults with acute major bleeding and reversal before an urgent surgery or invasive procedure for patients taking a vitamin K antagonist. This product’s labeling carries a boxed warning for the risk of both fatal and nonfatal thromboembolic complications, as it has not been specifically studied in patients who have had a thromboembolic event in the previous three months.1 Current data have shown that PCC is noninferior to plasma in the treatment of acute bleeding and International Normalized Ratio (INR) reversal.1 The antithrombotic guidelines recommend also administering vitamin K 5–10 mg i.v. to prolong the effect of PCC beyond 24 hours.2 Many studies and reports have also described the use of PCC for reversing the effect of novel oral anticoagulants, decreasing bleeding complications after cardiac surgery, and preventing bleeding complications in patients undergoing liver trans-
Purpose. The use of an off-label dose of four-factor prothrombin complex concentrate (PCC) for International Normalized Ratio (INR) reversal in a patient before a diagnostic lumbar puncture is reported. Summary. A 57-year-old, 122-kg man arrived at the hospital with a possible diagnosis of meningitis and had an INR of >3 while on warfarin therapy. The patient initiated warfarin therapy in 2009 due to recurrent deep vein thrombosis. The patient required reversal of his elevated INR in order for a lumbar puncture to be safely performed (INR must be no higher than 1.4). Multiple units of fresh frozen plasma (FFP) were administered, with a subsequent INR decrease to 1.9. Additional units of FFP were given. The patient developed respiratory decompensation due to volume overload, partially caused by the administration of
plantation and have directly compared PCC to fresh frozen plasma (FFP) and vitamin K (Rebbie M, CSL Behring, personal communication, 2014 Jan 10).2-7 One area of study with minimal supportive data is the use of PCC to reverse an INR of
ar Layar
Use of low-dose prothrombin complex concentrate before lumbar puncture Jared J. Butler
I
n April 2013, the Food and Drug Administration approved the first four-factor prothrombin complex concentrate (PCC) (Kcentra, CSL Behring) available in the United States. This product contains coagulation factors II, VII, IX, and X and proteins C and S at variable concentrations. Indications for PCC include urgent reversal of coagulation deficiency induced by vitamin K antagonists in adults with acute major bleeding and reversal before an urgent surgery or invasive procedure for patients taking a vitamin K antagonist. This product’s labeling carries a boxed warning for the risk of both fatal and nonfatal thromboembolic complications, as it has not been specifically studied in patients who have had a thromboembolic event in the previous three months.1 Current data have shown that PCC is noninferior to plasma in the treatment of acute bleeding and International Normalized Ratio (INR) reversal.1 The antithrombotic guidelines recommend also administering vitamin K 5–10 mg i.v. to prolong the effect of PCC beyond 24 hours.2 Many studies and reports have also described the use of PCC for reversing the effect of novel oral anticoagulants, decreasing bleeding complications after cardiac surgery, and preventing bleeding complications in patients undergoing liver trans-
Purpose. The use of an off-label dose of four-factor prothrombin complex concentrate (PCC) for International Normalized Ratio (INR) reversal in a patient before a diagnostic lumbar puncture is reported. Summary. A 57-year-old, 122-kg man arrived at the hospital with a possible diagnosis of meningitis and had an INR of >3 while on warfarin therapy. The patient initiated warfarin therapy in 2009 due to recurrent deep vein thrombosis. The patient required reversal of his elevated INR in order for a lumbar puncture to be safely performed (INR must be no higher than 1.4). Multiple units of fresh frozen plasma (FFP) were administered, with a subsequent INR decrease to 1.9. Additional units of FFP were given. The patient developed respiratory decompensation due to volume overload, partially caused by the administration of
plantation and have directly compared PCC to fresh frozen plasma (FFP) and vitamin K (Rebbie M, CSL Behring, personal communication, 2014 Jan 10).2-7 One area of study with minimal supportive data is the use of PCC to reverse an INR of
