Reversal Of Warfarin-Associated Coagulopathy: Prothrombin Complex Concentrates Versus Fresh Frozen Plasma In Elderly Patients Presenting With Intracranial Hemorrhage

Background: Patients on warfarin with traumatic intracranial hemorrhage (ICH) often require pharmacological reversal of warfarin-induced coagulopathy. We compared outcomes among patients who received 4-factor prothrombin complex concentrate (PCC), fresh frozen plasma (FFP) or no reversal to assess the real-world impact of PCC on elderly patients with traumatic intracranial hemorrhage on warfarin. Study Design: This was a retrospective analysis of 150 patients on preinjury warfarin. Data was abstracted from the electronic medical record (EMR) of an academic level 1 trauma center for patients age 65 years and greater on warfarin therapy admitted with a traumatic ICH between January 2013 and December 2018. Primary outcomes were ICH progression on follow-up computed tomography (CT) scan, in-hospital mortality, need for surgical intervention. Trends in use over time and costs of the reversal agents were also analyzed. Results: Of 150 patients eligible for analysis, 41 received FFP, 60 received PCC, and 49 were not reversed with either of those reversal agents. On multivariable analysis, patients who were not reversed [OR 0.25, 95% CI (0.31 – 0.85)] or were female [OR 0.38, 95% CI (0.17 – 0.88)] were less likely to experience progression of their initial bleed on follow-up CT. SDH increased the risk of hemorrhagic progression [OR 3.69, 95% CI (1.27 – 10.73)]. There was no difference between groups with respect to in-hospital mortality or the need for neurosurgical intervention. Over time, the use of reversal with PCC increased, while use of FFP and not reversing declined (p \u3c0.001). Regarding costs, PCC was significantly more expensive to administer per patient than FFP. Conclusion: In older patients with traumatic ICH on warfarin, use of a reversal agent was associated with progression of the ICH. The choice of reversal agent did not impact mortality or the need for surgery. Therefore, some ICH patients may not require warfarin reversal, and the apparent benefits to PCC use in retrospective studies may be related to the increased use of PCC in patients who would have not have otherwise been reversed