DOSING PROTHROMBIN COMPLEX CONCENTRATE (PCC)
For full details about dosing prothrombin complex concentrate (brand name= Kcentra), visit the manufacturer's website: http://www.kcentra.com. They also have an app you can download for dosing assistance. (I am in no way affiliated with this company and do not receive any financial reimbursement for this endorsement.)
Vitamin K dependent clotting factors made in the liver include the clotting factors II, VII, IX and X as well as the anticoagulant proteins, protein C and protein S. Warfarin is a Vitamin-K antagonist and works to block its effects in the production of these clotting factors. Tests used to measure these clotting factors include the PT/INR which become prolonged with the use of warfarin. Warfarin therapy is closely monitored via the PT/INR tests to avoid toxicities such as the formation of clots/stroke etc.
If a patient comes in with a very high INR and needs an urgent reversal of the drug (such as in acute major bleeding/ trauma, urgent surgery or invasive procedure, actively bleeding etc), we can give prothrombin complex concentrate (PCC, trade name K centra). PCC contains clotting factors II, VII, IX and X as well as protein C and protein S.
Dosing of Kcentra depends on the patient's weight and pre-treatment INR level.
INR Dose (IU/kg) Max Dose (IU) (100 IU/kg)
2-4 25 2500
4-6 35 3500
>6 50 5000
Dosing considerations for Warfarin reversal
Please note: You should encourage the clinician to give Vitamin K in addition to the K centra. K centra should be given IMMEDIATELY PRIOR to the procedure. The post-administration INR level does NOT need to be monitored/re-checked as it will not reflect the true in-vivo activity of the coagulation factors!!
STANDARD DOSING FOR WARFARIN REVERSAL
COMMON "OFF-LABEL" CONSULTS WE RECEIVE
Sometimes we get consulted for patients (such as those with liver disease) who are not taking warfarin, but are found to have an elevated INR, but need an emergent surgery/procedure. This is off-label usage!! When consulted, for these unique patient populations, we generally dose at a different concentration as seen below. Consult your Pathologist attending or fellow prior to making any decision.
Patients with chronic (liver/kidney/immune-mediated etc) disease and an elevated INR we may consider giving a lower dose, 10-15 units/kg, for these patients.
Another off-label request we often see is for Anti-Xa reversal (RivaroXaban, ApiXaban, EdoXaban etc) at which we dose at 50 units/kg. This is in-line with the most recent evidence/opinions.