Updated recommendations for warfarin reversal in the setting of four-factor prothrombin complex concentrate.

Introduction: Warfarin (vitamin K antagonist) remains an established anticoagulant for patients at high risk of arterial and venous thromboembolism. The prompt reversal of the anticoagulant effect of warfarin is necessary in the context of major bleeding or emergency surgery because of its extended inhibition of vitamin K-dependent coagulation factors for days. The mainstay of urgent warfarin reversal has been vitamin K administration, and infusion of a three-factor prothrombin complex concentrate (3FPCC) and the option for the addition of fresh frozen plasma as a source of factor VII. With the upcoming introduction in Australia and New Zealand of a four-factor prothrombin complex concentrate (4FPCC), which replaces all the vitamin K-dependent clotting factors, this article updates the previously published warfarin reversal guidelines.

Main recommendations: For urgent warfarin reversal, 4FPCC should be used instead of 3FPCC, using the same suggested dose. Vitamin K co-administration is still recommended for more sustained reversal.

Changes in management as a result of this statement: The use of 4FPCC for urgent warfarin reversal obviates the need for co-administration of fresh frozen plasma.