Elaina Etter, PharmD
PGY-2 Critical Care Pharmacy Resident
Grady Memorial Hospital
Atlanta
Disclosure information not submitted.
Lindsey Lindsey, PharmD
Emergency Medicine Pharmacy Resident
Grady Memorial Hospital
Atlanta, Georgia
Disclosure information not submitted.
Marjorie Curry, PharmD, BCOP
Pharmacist
Grady Health System, United States
Disclosure information not submitted.
Christopher Morrison, BCCCP, PharmD, FNCS
Pharmacist
Grady Memorial Hospital, United States
Disclosure information not submitted.
Katleen Chester, BCCCP, PharmD, BCGP
Pharmacist
Grady Health System, United States
Disclosure information not submitted.
Title: 4-Factor PCC Dosing for Urgent Anticoagulation Reversal in Patients with Obesity
Introduction: There is a lack of literature to guide 4-Factor Prothrombin Complex Concentrate (4F-PCC) dosing for anticoagulation reversal in obesity. Package insert recommendations state dosing weight should not exceed 100 kg, without consensus regarding the utilization of total body weight (TBW) or adjusted body weight (ABW) for optimal reversal.
Methods: A single-center retrospective cohort study was conducted on patients who received 4F-PCC for urgent reversal of warfarin or direct oral anticoagulants (DOAC) between May 1, 2018 and June 30, 2021. Patients were stratified into non-obese and obese cohorts, defined as a BMI > 30 kg/m2. Current institutional protocol allows 25-50 IU/kg (up to 100 kg) stratified by INR for warfarin reversal and 25-50 IU/kg for DOAC reversal. The primary objective was to characterize current 4F-PCC dosing practices in patients with obesity.
Results: Within the cohort of 178 patients, 49 patients were classified as obese. The median BMI was 34.5 kg/m2 (30.3 to 92.9 kg/m2) with 73.5% weighing over 100 kg. The most common indications for reversal were intracranial hemorrhage (53.1%) and gastrointestinal bleeding (26.5%). DOAC reversal was more common than warfarin reversal (61.2% vs. 38.8%). The most common indications for anticoagulation were atrial fibrillation (65.3%) and venous thromboembolism (24.5%). The median 4F-PCC dose was 2,500 IU. In the warfarin cohort, the median weight-based doses were 24 mg/kg TBW and 31 mg/kg ABW. In the DOAC cohort, the median doses were 23.4 mg/kg TBW and 29.9 mg/kg ABW. A dose of 25 IU/kg or less was ordered in the majority of DOAC patients (96.7%). Total body weight was utilized as the dosing weight in 89.5% of warfarin patients and 60% of DOAC patients. Four patients (8.2%) required an additional dose of 4-factor prothrombin complex concentrate.
Conclusions: Total body weight was more commonly utilized in dosing for warfarin reversal as compared to DOAC reversal, but the median total 4F-PCC dose did not differ significantly between the groups. Despite current policy allowing 4F-PCC doses up to 50 IU/kg for DOAC reversal, the majority of patients received 25 IU/kg or less. The median and weight-based doses of 4F-PCC are similar to published literature for warfarin reversal in obesity, despite this cohort presenting with a higher median BMI.