Should we transfuse Fresh Frozen Plasma (FFP) in a patient with Upper Gastrointestinal (UGI) bleed and an elevated International Normalized Ratio (INR) of 2.08?

FFP Transfusion for UGI Bleed with INR 2.08

Do not transfuse FFP for an INR of 2.08 in a patient with upper gastrointestinal bleeding—instead, use prothrombin complex concentrate (PCC) with vitamin K if reversal is needed, but proceed directly to endoscopy without delay. 1

Key Management Principles

INR Threshold and Reversal Strategy

• An INR of 2.08 does not require routine correction before endoscopy. The most recent international consensus guidelines (2019) explicitly state that no specific INR cutoff level mandates correction, and studies show no increased rebleeding risk with INR ≤2.5. 1

• Endoscopic treatment can be safely performed with INR <2.5. A cohort study demonstrated no differences in rebleeding, surgery, mortality, or complication rates in patients undergoing endoscopic therapy with INR 1.5-2.5 compared to non-anticoagulated controls. 1

• If reversal is deemed necessary, PCC is superior to FFP. Guidelines recommend vitamin K supplemented with intravenous four-factor PCC, with FFP used only if PCC is unavailable. 1

Why FFP Should Be Avoided

• FFP is ineffective at INR levels below 1.7. Research demonstrates that FFP transfusion fails to reliably reduce INR when the baseline INR is <1.7, with only 50% of patients at INR 1.7 showing significant change after FFP administration. 2

• FFP carries significant risks without benefit. In critically ill patients with coagulopathy (INR ≥1.5), FFP transfusion was associated with new-onset acute lung injury (18% vs 4%, p=0.021) without reducing bleeding episodes. 3

• PCC demonstrates superior efficacy and safety. In patients with GI hemorrhage due to warfarin, PCC achieved lower INR levels at 2 and 6 hours (1.53 vs 4.50 at 2 hours, p<0.01), resulted in zero active bleeding on endoscopy versus 35% with FFP (p<0.01), and shortened ED length of stay (1.62 vs 3.46 days, p<0.01). 4

Endoscopy Timing

• Do not delay endoscopy for coagulopathy correction. The 2019 international consensus strongly recommends proceeding with endoscopy without delay in anticoagulated patients, as early endoscopy (<24 hours) was not associated with increased rebleeding, thromboembolic events, or endoscopy-related adverse events. 1

• Rapid INR correction increases thrombotic risk. Use of reversal agents was associated with 4-fold higher risk of thromboembolism (OR 4.1, CI 1.0-16.5), and INR ≥2.5 with reversal carried 7-fold higher thromboembolism risk (OR 7.3, CI 1.5-35.3). 1

Clinical Algorithm for INR 2.08 with UGI Bleeding

Immediate Actions

• Assess hemodynamic stability and initiate resuscitation with restrictive transfusion strategy (hemoglobin threshold 70 g/L, or 80-100 g/L if cardiovascular disease present). 1, 5

• Proceed directly to endoscopy within 24 hours without waiting for INR correction. 1

• Hold anticoagulation temporarily but do not administer reversal agents unless life-threatening hemorrhage or need for emergent surgery. 1

If Reversal Is Required (Exsanguinating Hemorrhage Only)

• Administer vitamin K 10 mg IV by slow infusion. 1, 6

• Give four-factor PCC at appropriate dosing based on INR and body weight (typically 25-50 units/kg). 1, 4

• Avoid FFP unless PCC is unavailable, and if FFP must be used, dose adequately (not the common inadequate practice of 2 units). 1, 7

Post-Endoscopy Management

• Resume anticoagulation within 7 days once hemostasis is achieved, as prolonged discontinuation increases thrombotic risk 3-fold. 5, 8

• Monitor for cardiovascular complications for at least 72 hours, as intensive INR correction to <1.8 reduces mortality and myocardial infarctions. 1, 5

Critical Pitfalls to Avoid

• Do not reflexively transfuse FFP for mildly elevated INR. The common practice of giving 2 units of FFP is often insufficient and exposes patients to unnecessary transfusion risks without meaningful INR reduction at this level. 2, 7

• Do not delay endoscopy while attempting coagulopathy correction. Studies show anticoagulant interruption did not affect outcomes, and no increased risk was found with INR ≥2.5. 1

• Do not aggressively reverse anticoagulation unless life-threatening. Reversal agents significantly increase thromboembolism risk without reducing rebleeding rates. 1