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GI bleeding — UKMLA MCQ

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ModerateAnticoagulationGI bleedingUKMLAMRCP Part 1PSA

A 58-year-old man with atrial fibrillation takes warfarin. He presents with ongoing haematemesis and melaena. Despite initial intravenous fluid resuscitation, his blood pressure is 86/54 mmHg and pulse is 118 beats/min. His haemoglobin has fallen from 132 g/L to 86 g/L, and his INR is 2.8. Which treatment is most appropriate for immediate reversal of his anticoagulation?

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Correct answer: E — Four-factor prothrombin complex concentrate plus intravenous phytomenadione

This is major, potentially life-threatening gastrointestinal haemorrhage, so warfarin requires immediate reversal even though the INR is within the usual therapeutic range. Four-factor prothrombin complex concentrate rapidly replaces factors II, VII, IX and X, while intravenous phytomenadione sustains reversal after the infused factors are cleared. Fresh frozen plasma is slower, requires a larger infusion volume and is reserved for situations in which PCC is unavailable. Phytomenadione alone is inadequate because its effect is delayed for several hours. Simply withholding warfarin does not provide sufficiently rapid reversal during active major bleeding. Protamine reverses unfractionated heparin and partially reverses low-molecular-weight heparin; it does not reverse warfarin.

Reference: Konakion MM 10 mg/ml solution for injection, Summary of Product Characteristics, section 4.2: severe or life-threatening haemorrhage, revised 5 February 2024. https://www.medicines.org.uk/emc/product/9755/smpc