Warfarin Reversal: Time for a Change?

Mark J. Alberts, MD


January 23, 2014

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Hello, and welcome to this Medscape stroke update. I am Dr. Mark Alberts, Vice Chair of Neurology at UT Southwestern in Dallas.

Today I want to talk about a recent study published in the journal Circulation by Hickey and colleagues.[1] This retrospective study looked at adults who were taking warfarin at an international normalized ratio of 1.5 or greater and who had a serious bleeding event, typically either a gastrointestinal hemorrhage or an intracerebral hemorrhage, from 2006 to 2010.

The investigators evaluated outcomes of patients who were treated with fresh frozen plasma (FFP) using the usual dosing paradigm vs a relatively new prothrombin complex concentrate (PCC) called Octaplex®.

The primary endpoint of this study was the occurrence of stroke, myocardial infarction, death, or ischemic events in the patients who were treated with normal FFP in a dose that was standard for the patient vs those treated with Octaplex in a dose of 1000-1500 IU. This was a relatively large study: 149 patients received FFP, and 165 patients received Octaplex.

In all, 20% of patients in the FFP group met the primary endpoint vs 10% in the Octaplex group, a statistically significant difference in favor of Octaplex. Moreover, the study found that the time for reversal of the warfarin-induced coagulopathy was almost 12 hours for patients who received FFP vs 5.7 hours for patients who received Octaplex.

The bottom line of this study was that this relatively new PCC worked better than FFP in reducing the occurrence of stroke, myocardial infarction, death, or ischemic events, and it worked faster than the FFP.

This is not the first study to show this, although it was one of the larger studies. In my opinion, looking at the whole body of evidence, the reversal of coagulation, particularly significant bleeding events in the setting of warfarin therapy, is moving away from the use of FFP and more in favor of a PCC because the PCC seems to work better with fewer ischemic changes, and it more rapidly reverses the coagulopathy.

Thank you for joining me for this Medscape stroke update.


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