Case series of low dose four-factor prothrombin complex concentrate for anticoagulant reversal

Introduction: Recent international guidelines recommend the use of 4-factor prothrombin complex concentrate (PCC4) over fresh frozen plasma (FFP) for reversal of oral anticoagulant in life-threatening bleeds. Although, thromboembolic complications were reported in many studies in patients who received PCC4. Objective: Describe the effectiveness and safety of low weight base dose (25mg/kg) 4-factor prothrombin complex concentrate (PCC4) in controlling bleeds event caused by oral anticoagulant. Methods: Retrospective case series included nine patients who visit Emergency department with acute bleeding events controlled with low weight base dose 4-factor prothrombin complex concentrate. Chart review was conducted between January 2017 and December 2018. International Normalized Ratio (INR), thromboembolic events and hypersensitivity reaction were documented. Results: Baseline mean [±SD] INR ([±5.3] 6.4), Anticoagulant caused Intracerebral hemorrhage in two patients, and Gastrointestinal bleeding was the most complication caused by anticoagulant. PCC4 was given in dosing range 25 unit/kg based on estimated patient weight, mean [±SD] INR ([±0.95] 1.6) was 60 minutes post PCC4, PCC4 contributed significant reduction in INR (p=0.02). Six patients reached INR < 1.5, two patients INR <2, and only one patient with INR 4.3. No addition PCC4 doses were needed to control the bleeding event. None of patients experienced a thromboembolic events or hypersensitivity reaction 30 days post PCC4. Conclusion: Low weight base dose (25 unit/kg) PCC4 contributed to efficient reduction of INR in patients with life-threatening bleeding with low risk of thromboembolism event. We recommend a larger study to evaluate INR rebound and re-bleeding for post PCC4 along with thromboembolism event beyond the 30 days.