Practical management of coagulopathy associated with warfarin
BMJ 2010; 340 doi: https://doi.org/10.1136/bmj.c1813 (Published 19 April 2010) Cite this as: BMJ 2010;340:c1813
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1)Rapidly consult with a consultant haematologist
2)Ascertain the need for immediate O negative blood transfusion.
3)In the United Kingdom, concise guidelines are rapidly accessible
and regularly updated, in the British National Formulary, in the section
on oral anticoagulants, subtitled "Haemorrhage".
4) Averting the crisis: serial measurements of Full Blood Picture in
asymptomatic patients, may point to the presence of occult bleeding.
Competing interests:
None declared
Competing interests: No competing interests
Sir,
It was heartening to see Dr Garcia and colleagues mention that
patients, who bleed, while on anticoagulant medications like warfarin,
should be investigated for the cause of bleeding. It is very often that a
bleeding source like gastrointestinal ulcer has initiated the bleeding
which is then worsened by warfarin. In this context, it is also important
to stress that the activated partial thromboplastin time or APTT should be
measured in addition to the INR in patients who present with warfarin-
related bleeding. This part of the coagulation is often overlooked,
presumably because the bleeding in patients on warfarin is considered only
to be due to the anticoagulant drug. Disseminated intravascular
coagulation is a possibility in patients admitted to hospitals with severe
infections, pancreatitis or disseminated malignancies and these patients
are very often also on anticoagulant medications [1]. The diagnosis of DIC
would be overlooked in these cases, if only the INR is checked and the
APTT is not measured. A typical scenario which should raise suspicion of
DIC is when the INR remains prolonged after the administration of vitamin
K in non-life threatening bleeds. Another easily missed condition is
acquired haemophilia. This is a less recognised cause for extensive
subcutaneous bruising and sometimes life-threatening haemorrhage in older
individuals (the same individuals who are more likely to be on warfarin)
[2]. Once again this diagnosis can only be suspected if APTT is measured
along with INR and further studies are undertaken to confirm antibodies to
factor VIII. So let’s remember, all that bleeds is not due to warfarin.
References
1. Levi M, Toh CH, Thachil J, Watson HG. Guidelines for the diagnosis and
management of disseminated intravascular coagulation. British Committee
for Standards in Haematology.
Br J Haematol. 2009 Apr;145(1):24-33
2. Huth-Kühne A, Baudo F, Collins P, Ingerslev J, Kessler CM, Lévesque H,
Castellano ME, Shima M, St-Louis J. International recommendations on the
diagnosis and treatment of patients with acquired hemophilia A.
Haematologica. 2009 Apr;94(4):566-75.
Competing interests:
None declared
Competing interests: No competing interests
Thanks for the timely article on the reversal of warfarin in effect
in clinical practice.It is still a very grey area when it comes to
difficult clinical situations especially in somebody with a prosthetic
heart valve and moderate bleeding.If the bleeding is life threatening
obviously there is no choice but to reverse the high INR.Warfarin is a
nightmare especially for junior doctors and nurses who are most involved
in the use of warfarin in inpatients. The use of prothrombin complex has
altered the reversal of warfarin effect as it is very short acting and
better than the fresh frozen plasma.The interesting point is that the
patient still needs Vitamin K for a much more uniform reversal. And again
higher doses of vitamin K might lead to prolonged suppression of INR and
may have a procoagulant effect.The common scenario is that of a prosthetic
valve patient getting ten mg of vitamin K for a high INR.And in some
instances vitamin K is given intramuscularly leading to a big
haematoma.Oral vitamin K is still the preferred route for minor bleeds but
for some elderly patients,alcoholics,inflammatory disease and heart
failure patients intravenous vitamin K is better.I am not sure when the
new anticoagulant comes in there will be an antagonist? We will have to
wait and see.
Competing interests:
None declared
Competing interests: No competing interests
Congratulation for this precious paper!
I think clinicians would like to ask another question.
What to do after a life threatening bleeding (like intracerebral
haemorrhage). Should we restart warfarin or not?
Competing interests:
None declared
Competing interests: No competing interests
Sir,
We have read with great interest the article by Garcia et al. (1) on the
practical management of coagulopathy associated with warfarin. The paper
is timely and very useful to physicians as it provides straightforward
indications for everyday clinical decision-making on a topic which is
still poorly known. Indeed, we recently conducted a survey among
endoscopists in northern Italy on the management of vitamin K antagonists
coagulopathy in acutely GI bleeding patients, which consisted of four
hypothetical clinical scenarios representing various combinations of INR
values and severity of bleeding in patients receiving warfarin therapy for
different clinical indications (2). The results of the survey documented a
wide variability of attitudes among respondents with a 30% adherence to
the recommendations of published guidelines (3). This results are
disquieting, but they are in line with those reported in a previous survey
held among members of Canadian Society of Internal Medicine who were
supposed to be acquainted with management of warfarin anticoagulation (4).
All these data seem to suggest a scarce attention toward strategies of
dissemination and implementation of practice guidelines, that conversely
should be an integral part of their development process. On the basis of
the above considerations, articles aimed at improving the implementation
of guidelines through a more “practical” approach to the problems deserve
great appreciation.
REFERENCES:
1) Garcia D, Crowther MA, Ageno W. Practical management of coagulopathy
associated with warfarin. BMJ 2010; 140: 918-20
2) Paggi S, Radaelli F, Manes G, Meucci G, Saibeni S. The Management of
Warfarin-Associated Coagulopathy in the Acutely GI Bleeding Patients: A
Survey of Current Practice. Gastrointest Endosc 2010; 71: AB212
3) Ansell J, Hirsh J, Hylek E, Jacobson A, Crowther MA, Palareti G.
Pharmacology and management of the vitamin K antagonists. American College
of Chest Physician. Evidence-based clinical practice guidelines. Chest
2008; 133: 160S-198S
4) Wilson SE, Douketis JD, Crowther MA. Treatment of warfarin-associated
coagulopathy: a physician survey. Chest. 2001; 120: 1972-6
Competing interests:
None declared
Competing interests: No competing interests
Oral anticoagulant reversal and urgent surgery
Sir,
A not infrequent request for advice on oral anticoagulant reversal is
urgent surgery, when in the absence of haemorrhage prothrombin complex
concetrate (PCC) is unlicensed. The prompt use of intravenous vitamin K,
titrated for the INR, will generally start to reduce the INR within four
hours and so may enable surgery to safely proceed. When delay is not
possible or the INR fall insufficent, PCC administration is appropriate.
Post operatively consideration should be given to "bridging" anticoagulant
therapy in line with guidance.
Referance: American College of Chest Physicians Antithrombotic and
Thrombolytic Therapy Practice Guideline 8th edition 2008
Competing interests:
None declared
Competing interests: No competing interests