Role of Octaplex (Prothrombin Complex Concentrate) in Managing Intracranial Hemorrhage Associated with Warfarin
Prothrombin complex concentrate (PCC) such as Octaplex is strongly recommended as the first-line treatment for rapid reversal of warfarin-associated intracranial hemorrhage, and should be administered with intravenous vitamin K to achieve an INR <1.5. 1
Emergency Management Algorithm
Initial Assessment and Treatment
- Immediately discontinue warfarin upon diagnosis of intracranial hemorrhage (ICH) 1
- Administer 4-factor PCC (such as Octaplex) as soon as possible, without waiting for INR results 1
- Dosing should be based on INR and body weight (25-50 IU/kg) 1
- For INR ≥2.0: Use standard dosing protocol 1
- For INR <2.0 but ≥1.3: Consider lower dose of 10-20 IU/kg 1
Concurrent Treatments
- Always administer intravenous vitamin K (5-10 mg) alongside PCC to prevent rebound increases in INR 1
- Target INR correction to <1.5 1
- Monitor INR at 1 hour post-administration and again at 24 hours 2
Evidence Supporting PCC Use
Advantages Over Fresh Frozen Plasma (FFP)
- PCCs correct INR more rapidly than FFP (median time to correction: 85 minutes with PCC vs. 6.75 hours with FFP) 2, 3
- Higher rate of effective INR reversal with PCC compared to FFP (90.3% vs 69.7%) 3
- PCCs do not require blood group compatibility testing or thawing 1
- Lower risk of volume overload, transfusion reactions, and acute lung injury compared to FFP 1, 4
Specific Benefits of Octaplex
- Octaplex is a 4-factor PCC containing factors II, VII, IX, X and natural anticoagulants (proteins C and S) 4
- Demonstrated rapid correction of INR from median 2.8 to 1.1 within 10 minutes of administration 4
- Allows for expedited neurosurgical intervention when needed 2
Safety Considerations
- Monitor for potential thromboembolic complications, although the risk appears relatively low 5
- Higher doses of PCC (>2000-3000 IU) may increase risk of venous thromboembolism 1
- Consider patient's underlying thrombotic risk factors before administration 1
- Avoid recombinant activated factor VII (rFVIIa) as first-line therapy due to increased thromboembolic risk, especially in elderly patients 1
Clinical Outcomes
- Rapid INR correction with PCC is associated with reduced hematoma expansion 1
- Early administration (within 4 hours) combined with blood pressure control is associated with lower in-hospital mortality 1
- Facilitates timely neurosurgical intervention when indicated 2
Considerations for Resuming Anticoagulation
- The decision to restart anticoagulation should balance thromboembolic risk against risk of recurrent hemorrhage 1
- Limited data suggest that reinstitution of warfarin after 7-10 days may be safe in selected patients 1
- For patients with lower thromboembolic risk and higher bleeding risk (especially elderly with lobar hemorrhage), consider antiplatelet agents instead of warfarin 1