Factor Eight Inhibitor Bypassing Activity (FEIBA) for the Rapid Reversal of Major Bleeding in Patients with Warfarin Induced Coagulopathy: A Pilot Study David Barounis, MD 1 Catherine Knight, MD 2 Ben-Paul Umunna, MD 2 Mary Hormese, PharmD, BCPS 2 Elise Lovell, MD 2 1 Stanford University, Stanford, CA; 2 Advocate Christ Medical Center, Oak Lawn, IL
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Factor Eight Inhibitor Bypassing Activity (FEIBA) for the Rapid Reversal of Major
Bleeding in Patients with Warfarin Induced Coagulopathy: A Pilot Study
David Barounis, MD1
Catherine Knight, MD2 Ben-Paul Umunna, MD2
Mary Hormese, PharmD, BCPS2
Elise Lovell, MD2
1Stanford University, Stanford, CA; 2Advocate Christ Medical Center, Oak Lawn, IL
No financial disclosures or conflict of interest
Background• Fresh frozen plasma (FFP) + vitamin K to
reverse major bleeding due to warfarin associated coagulopathy
• FFP shortcomings▫incomplete reversal▫time delay for ABO compatibility, thawing▫large volume ▫time to transfuse▫risk of TRALI
• Prothrombin complex concentrates (PCC)recommended since 2012
Clinical Experience with FEIBA• Retrospective comparison of 72 pts receiving
FEIBA to 69 patients receiving FFP• Median time to reversal of INR < 1.4 was 2 hours
in FEIBA group, 25 hours in FFP group• 7% TAE, 22% mortality in FEIBA group
Wojcik C, Schymik ML, Cure EG. Activated prothrombin complex concentrate factor VIII inhibitor bypassing activity (FEIBA) for the reversal of warfarin-induced coagulopathy. Int J Emerg Med 2009;2:217-225.
Study Purpose•To evaluate the efficacy and safety of
FEIBA and IV vitamin K for the reversal of warfarin-associated coagulopathy in patients with major hemorrhage
Hypothesis•The use of FEIBA and IV vitamin K will
result in the rapid reversal of warfarin associated coagulopathy in patients with major bleeding
•Adverse event rate will be low
Methods - Study Setting•Tertiary care suburban community
teaching hospital•100,000 ED visits per year•700 inpatient beds
Methods - Study Design•Ongoing prospective, observational study•ED patients on warfarin presenting with
major bleeding•INR ≥ 5.0 1000U of FEIBA •INR < 5.0 500U of FEIBA IV•10mg IV vitamin K•Repeat INR 30 minutes, 4 and 24 hours
Inclusion Criteria•Age > 18•Present to the ED with major hemorrhage
while on warfarin▫life or limb threatening bleed or▫bleed in critical location (intracranial,
ophthalmic, intraspinal) or▫2 gram fall in hemoglobin
•Initial INR >1.5
Exclusion Criteria•Coagulopathy not due to warfarin•On warfarin, but INR ≤ 1.5•No major hemorrhage•Received additional reversal agents prior
to/in ED (FFP, aFactor VII, PCCs, vitamin K PO/SQ/IM)
Methods of Measurement•All eligible patients identified by M/W/F
review of FEIBA dispensed to ED
Outcome Measures•Primary Outcome: Time to INR ≤ 1.5•Secondary outcomes:
▫Thrombotic adverse events, allergic reaction
▫FEIBA dose required to reverse▫Units of PRBCs transfused▫Mortality
Statistical Analysis•Reporting of descriptive measures
(means, medians, IQRs, as appropriate)
Results• Between 2/8/2013 and 8/30/2013, 44 ED patients
received FEIBA• 9 did not meet inclusion criteria
▫6 not major bleed▫3 INR ≤ 1.5
• 14 patients excluded ▫6 FFP or alternate route vitamin K▫4 died before consent obtained▫1 no POA▫1 withdrew consent▫2 ethical issue to approach for consent
• Mean initial INR was 5.5• 16/21 patients admitted to ICU for at least 1 day• Achieved INR ≤ 1.5 in all patients• Mean time to INR ≤ 1.5 was 127 minutes
▫1 patient’s repeat INR was drawn ~12 hrs after FEIBA
▫if this patient excluded, mean time to INR ≤ 1.5 was 98 minutes
78 yo male CNS bleed herniation/withdrawal of care
2
41 yo male GI bleed GI bleed/arrest 1276 yo male GI bleed GI bleed/arrest 1888 yo female CNS bleed withdrawal of
care8
Results: TAEDiagnosis History TAE Hospital DayGI bleed DVT DVT on US; not
definitively acute vs chronic
3
CNS bleed severe arterial dz, multiple arterial clots, afib, valve
ischemic CVA + arm DVT
715
CNS bleed titanium aortic valve, afib
embolic ischemic CVA
18
TAE: Background•Kcentra: 9% TAE vs. 5.5% TAE in FFP group
(ns)
•Wojcik: 1.4% TAE in FFP group
•MEDENOX trial: 15% rate of DVT in patients admitted without SQ enoxaparin
•FEIBA in hemophilia: TAE rate of 4 per 100,000 infusions
Limitations•Single center•Observational study design•Disease oriented primary outcome•4 patients died before consent obtained
(impacts mortality rate)•Contribution of FEIBA to thrombotic
adverse events uncertain
Conclusions•FEIBA and IV vitamin K result in rapid
reversal of warfarin-induced coagulopathy in patients with major bleeding
•Thrombotic adverse event rate was 14%
23
What about Kcentra? •FDA approved April 30, 2013•PCC given along with Vitamin K
▫Factors II, VII, IX, X, with proteins C and S, antithrombin III
▫Includes heparin•Dosing based on INR, body weight•No repeat dosing•Known risks
Cost of FEIBA vs FFP•Feiba: $1.48 per unit
▫Hospital cost: $740 for 500 units, $1480 for 1000 units
▫Patient cost: $3,496 and $5,920•FFP: $65 -70 per unit, start with 10 cc/kg,
200 cc in unit of FFP, so 100 kg pt needs 5 units FFP = $350
4 Patients with 3 TAEs• Leg DVT, 2 ischemic CVAs, and arm DVT. One pt
with both arm DVT and CVA. • Pt with leg DVT admitted with GI Bleed, had h/o
DVT. US hospital day 3 with DVT which could not be definitively called acute versus chronic.
• Pt with arm DVT and CVA admitted with acute on chronic subdural hematoma, h/o severe arterial disease/multiple peripheral arterial clots, also mitral valve replacement, afib
• Pt with other CVA (thought to be embolic) admitted with SAH, had h/o titanium aortic valve and afib.
Clinical Experience with FEIBA•FEIBA usage summarized in 16 patients at
community hospital•87% of patients survived to discharge•No signs or symptoms of TAE
Stewart WS, Pettit H. Experiences with an activated 4-factor prothrombin complex concentrate (FEIBA) for reversal of warfarin-related bleeding. AJEM 2013; 31:1251-1254.