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Archived Comments for: Emergency correction of coagulation before major surgery in two elderly patients on oral anticoagulation

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  1. Recombinant activated factor VII for emergency correction of coagulation before major surgery in the elderly.

    Giuseppe Lippi, Sezione di Chimica Clinica, Dipartimento di Scienze Morfologico-Biomediche, Università degli Studi di Verona, Italy

    6 March 2008

    I read with interest the article of Angelo et al., describing two cases of orally anticoagulated patients over 75 years of age whose prolonged International Normalized Ratios (INRs) were corrected with prothrombin-complex concentrates (PCCs) ahead of surgical treatment of a bleeding ruptured spleen and for emergency surgery of a dissecting aorta (1). It was concluded that in the two presented cases PCC was effective and safe in reversing oral anticoagulation.

    A timely reversal treatment of excessive anticoagulation is essential in several clinical circumstances, such as urgent surgery, along with an efficient anti-haemorrhagic prophylaxis to prevent further bleeding. According to available guidelines, current recommendations for emergency anticoagulant reversal mainly apply to adult patients independent of age and include the use of PCC. This strategy is however challenging in the elderly, since many studies reported orally anticoagulated patients mainly <75 years of age who are at lower risk of both, bleeding as well as atherothrombotic complications. In this respect, the article of Angelo et al. is valuable, in that it demonstrates that patients older than 75 years of age might benefit from PCC used for immediate correction of life-threatening INRs without additional risks or relevant side effects. However, it is also to mention that alternative strategies might be devised to overcome this problem besides PCC administration.

    Recombinant activated factor VII (rFVIIa) is an hemostatic agent that was originally designed for the treatment of hemorrhage in patients with hemophilia and inhibitors. However, in the last few years rFVIIa has been employed successfully in a broad spectrum of congenital and acquired bleeding conditions and, on the whole, data in the literature suggest a potential role for rFVIIa in the management of bleeding unresponsive to standard therapy (2). Recent clinical evidences demonstrate that low-dose rFVIIa appears to be an effective, rapid reversal modality for major bleeding events in the presence of warfarin and an elevated INR (3-5), which can be efficaciously used also in emergency situations, such as urgent surgery (3). Moreover, due to the good correlation with factor VII clotting activity, a simple INR test can be reliably used for monitoring rFVIIa therapy (6). Preliminary reports indicate that besides its actual high costs, rFVIIa might be a useful and safe, noninvasive therapeutic tool in selected cases also in the elderly (7,8). Although trials with larger numbers of patients are needed to establish the most appropriate doses and timing of rFVIIa, especially in the aged population, and to assess its efficacy and safety in this particular clinical setting, I suggest that administration of rFVIIa might be a valuable prophylactic aid to urgently reverse elevated INRs ahead of surgery, thus preventing life-threatening haemorrhages.

    References

    1. Angelo M, Gutmann B, Adami M, Zagler B, Zelger A, Pechlaner C, Wiedermann CJ: Emergency correction of coagulation before major surgery in two elderly patients on oral anticoagulation. Thromb J 2007;5:1.

    2. Franchini M, Veneri D, Lippi G: The potential role of recombinant activated FVII in the management of critical hemato-oncological bleeding: a systematic review. Bone Marrow Transplant 2007 Apr 9; [Epub ahead of print]

    3. Dager WE, King JH, Regalia RC, Williamson D, Gosselin RC, White RH, Tharratt RS, Albertson TE: Reversal of elevated international normalized ratios and bleeding with low-dose recombinant activated factor VII in patients receiving warfarin. Pharmacotherapy 2006;26:1091-8.

    4. Schulman S, Bijsterveld NR: Anticoagulants and their reversal. Transfus Med Rev 2007;21:37-48.

    5. Ingerslev J, Vanek T, Culic S: Use of recombinant factor VIIa for emergency reversal of anticoagulation. J Postgrad Med 2007;53:17-22.

    6. Lippi G, Montagnana M, Salvagno GL, Poli G, Franchini M, Guidi GC: Influence of warfarin therapy on activated factor VII clotting activity. Blood Coagul Fibrinolysis 2006;17:221-4.

    7. Ali ZS, Al-Shaalan H, Jorgensen J: Successful treatment of massive acute lower gastrointestinal bleeding in diverticular disease of colon, with activated recombinant factor VII (NovoSeven). Blood Coagul Fibrinolysis 2006;17:327-9.

    8. Dragani A, Di Bartolomeo E, La Barba G, Cavoni A, Lanzillotta P, Guizzardi G, Davì G: Recombinant activated factor VII therapy in acquired hemophilia of the elderly. Aging Clin Exp Res 2004;16:487-9.

    Competing interests

    None

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