What is the management of vitamin K deficiency?

From the Guidelines

Management of vitamin K deficiency involves prompt administration of vitamin K supplementation, with the specific approach depending on the severity and cause of the deficiency, and according to the most recent guidelines, oral vitamin K (phytonadione) at 1-10 mg daily is recommended for older children and adults, while infants should receive 0.3-1.0 mg/day 1.

Key Considerations

• The severity and cause of the deficiency should guide the treatment approach
• Vitamin K1 (phytomenadione) is the recommended form of supplementation due to its safety profile and effectiveness
• Monitoring of coagulation parameters is necessary to assess response to treatment and adjust dosing accordingly

Treatment Approaches

• For mild to moderate deficiency without active bleeding, oral vitamin K (phytonadione) at 1-10 mg daily is typically effective
• In severe cases with active bleeding or critically high INR values, intravenous vitamin K at 5-10 mg should be administered slowly over 20-30 minutes to avoid anaphylactoid reactions
• For life-threatening bleeding, fresh frozen plasma or prothrombin complex concentrate may be needed alongside vitamin K

Special Considerations

• Newborns, especially those who are exclusively breastfed, should receive a single prophylactic dose of 0.5-1 mg vitamin K intramuscularly at birth to prevent hemorrhagic disease
• Patients on warfarin with supratherapeutic INR may require lower doses of 1-2.5 mg oral vitamin K
• Treatment duration varies based on the underlying cause, with dietary deficiency potentially requiring several weeks of supplementation, while warfarin reversal may need only a single dose

Evidence-Based Recommendations

• The most recent guidelines recommend regular supplementation of vitamin K1 at 0.3-1.0 mg/day for infants and 1-10 mg/day for older children and adults, depending on age and risk factors 1
• The use of vitamin K2 (menaquinone) is not widely recommended due to limited availability and lack of studies on its effectiveness in clinical trials 1
• Four-factor prothrombin complex concentrates (4F-PCCs) are preferred over plasma for rapid VKA reversal due to their higher concentration of vitamin K-dependent factors and faster infusion rate 1

From the Research

Management of Vitamin K Deficiency

The management of vitamin K deficiency involves the administration of vitamin K to prevent or treat bleeding complications. The following are some key points to consider:

• Vitamin K should be administered to all neonates at birth or immediately afterwards to prevent vitamin K deficiency bleeding (VKDB) 2.
• The optimal mode of neonatal prophylaxis remains to be determined, but options include oral or parenteral vitamin K administration 3, 2.
• For formula-fed neonates without risk of hemorrhage, a 2 mg oral dose of vitamin K at birth, followed by a second 2 mg oral dose between day 2 and 7, is probably sufficient to prevent VKDB 2.
• For infants who are exclusively or nearly exclusively breast-fed, weekly oral administration of 2mg (or 25 microg/day) vitamin K after the initial 2 oral doses is justified at completion of breast-feeding 2.
• For neonates at high risk of hemorrhage, the first dose must be administered by the intramuscular (IM) or slow intravenous route, and doses should be repeated as needed 2.
• In cases of vitamin K deficiency bleeding, treatment with intravenous vitamin K therapy (5 mg/d) for 3 d can normalize coagulation tests and improve symptoms 4.
• Laboratory assessment of vitamin K status can be done through measurement of phylloquinone (K1) in serum, and undercarboxylated prothrombin (PIVKA-II) can be used as a retrospective indicator of hepatic vitamin K status 5.

Prevention of Vitamin K Deficiency Bleeding

Prevention of vitamin K deficiency bleeding is crucial, especially in neonates. Some key points to consider:

• A single dose of oral or parenteral vitamin K prevents classic hemorrhagic disease of the newborn (HDN), but the most effective way to prevent early HDN is by giving large doses to the mother prior to delivery 3.
• Parenteral (1 mg) vitamin K1 prevents late HDN, and single or repeated doses of oral vitamin K reduces the incidence but does not eliminate all late HDN 3.
• Different oral dose schedules of vitamin K have been shown to be effective in preventing late VKDB, including daily supplementation of low dose vitamin K (25 micrograms) for breast-fed infants, and 3 x 1 mg orally 6.
• The effectiveness of different modes of vitamin K prophylaxis, including oral and parenteral administration, depends on various factors, including the dose and route of administration, and the individual patient's risk factors 2, 6.