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. 2017 Mar 15;8:80. doi: 10.3389/fneur.2017.00080

Table 2.

Guidelines for vitamin K antagonists (VKAs) reversal.

  • (1)

    Discontinue VKAs when ICH is present or suspected (good practice statement)

  • (2)

    Urgent reversal of VKAs in patients with ICH with the following exceptions (strong recommendation, moderate quality evidence)

    1. High suspicion of ICH due to cerebral venous thrombosis (conditional recommendation, very low-quality evidence)

    2. In patients with concurrent symptomatic or life-threatening thrombosis, ischemia, heparin-induced thrombocytopenia, or DIC (good practice statement)

  • (3)

    Administration of vitamin K as soon as possible or concomitantly with other reversal agents (strong recommendation, moderate quality evidence). The following dosing is recommended:

    1. One dose of vitamin K 10 mg IV

    2. Subsequent treatment should be guided by follow-up international normalizing ratios (INRs) (good practice statement)

    3. If repeat INR is still elevated C 1.4 within the first 24–48 h after reversal agent administration, redose with vitamin K 10 mg IV (good practice statement)

  • (4)

    Administer 3-factor or 4-factor prothrombin complex concentrates (PCCs) rather than fresh frozen plasma (FFP) to patients with INR >1.4 (strong recommendation, moderate quality evidence)

    1. 4-factor PCC is preferred over 3-factor PCC (conditional recommendation, low-quality evidence)

    2. Suggest initial reversal with PCC alone rather than combined with FFP or recombinant FVIIa (rFVIIa) (conditional recommendation, low-quality evidence)

    3. PCC dosing should be weight-based and vary according to admission INR and type of PCC used (strong recommendation, moderate quality evidence)

    4. INR testing should be repeated soon after PCC administration (15–60 min), and serially every 6–8 h for the next 24–48 h.

    5. Subsequent treatment should be guided by follow-up INR.

    6. Repeat PCC dosing may lead to increased thrombotic complications and risk of DIC.

    7. If repeat INR is still elevated >1.4 within the first 24–48 h after initial PCC dosing, suggest further correction with FFP.

  • (5)

    Recommend against administration of rFVIIa for the reversal of VKA (strong recommendation, low quality evidence)

  • (6)

    If PCCs are not available or contraindicated, alternative treatment is recommended over no treatment (strong recommendation, moderate quality evidence)

    1. Treatment with FFP and vitamin K is recommended over no treatment (strong recommendation, moderate quality evidence)

    2. Suggest dosing FFP at 10–15 ml/kg IV along with one dose of vitamin K 10 mg IV (conditional recommendation, low-quality evidence)