Urgent warfarin reversal with fast and sustained action vs plasma*

• For patients presenting with acute GI bleeding and on warfarin–we suggest PCC compared with plasma administration

• 4-F PCC is recommended in preference to plasma in patients with VKA-associated spontaneous ICH and INR ≥2.0, to achieve rapid correction of INR and limit HE.
• It may be reasonable to use PCC to achieve rapid correction of INR and limit HE in patients with VKA-associated spontaneous ICH with INR of 1.3 to 1.9.
• In patients with direct factor Xa inhibitor–associated spontaneous ICH, a 4-F PCC or activated PCC (aPCC) may be considered to improve hemostasis.
• In patients with dabigatran-associated spontaneous ICH, when idarucizumab is not available, aPCC or PCCs may be considered to improve hemostasis.

For reversal of warfarin, administer 4F-PCC:

• INR 2 to <4, 25 units/kg
• INR 4-6, 35 units/kg
• INR >6, 50 units/kg

Or low fixed-dose option:

• 1000 units for any non-intracranial major bleed
• 1500 units for ICH

• Non-bleeding patients: 2.5-25 mg PO to decrease INR, Major bleeding: 5 to 10 mg slow IV injection, in addition to 4-factor PCC

• Administer vitamin K and 4-factor PCC to patients with an elevated INR secondary to warfarin who are actively bleeding and/or require urgent operation.

• For patients with life-threatening bleeding during VKA treatment of VTE who have an elevated INR, the ASH guideline panel suggests using 4-F PCCs rather than plasma
• For patients with life-threatening bleeding during oral direct Xa inhibitor treatment of VTE, the ASH guideline panel suggests using either 4-factor PCC administration as an addition to cessation of oral direct Xa inhibitor or cessation of oral direct Xa inhibitor alone.

• Recommend administering 3-factor or 4-factor PCC rather than plasma to patients with VKA-associated intracranial hemorrhage and INR ≥1.4.

• This Circular was prepared jointly by the AABB, the American Red Cross, America's Blood Centers, and the Armed Services Blood Program. The Food and Drug Administration recognizes this Circular of Information as an acceptable extension of container labels.
• Do not use plasma when coagulopathy can be corrected more effectively with specific therapy, such as vitamin K, cryoprecipitated AHF (antihemophilic factor), prothrombin complex concentrates used to reverse warfarin, or specific coagulation factor concentrates.

• For patients with VKA-associated major bleeding, we suggest rapid reversal of anticoagulation with four-factor prothrombin complex concentrate (PCC) rather than with plasma.