Prevention of treatment-related fluid overload reduces estimated effective cost of prothrombin complex concentrate in patients requiring rapid vitamin K antagonist reversal

Abstract

Introduction: Fresh frozen plasma (FFP) is a frequently used human blood product to reverse the effects of vitamin K antagonists. While FFP is relatively economical, its large fluid volume can lead to hospitalization complications, therefore increasing the overall cost of use. Materials & methods: A recently published article by Sarode et al., in Circulation, described the rate of volume overload associated with FFP use for reversal of vitamin K antagonists. This condition, described as transfusion-associated circulatory overload, has a defined rate of intensive care admission, which also has a well-reported average cost. The additional monetary value of intensive care unit admission and caring for fluid overload is then compared to the cost of another product, four-factor prothrombin complex concentrates, which does not, as per the Sarode paper, result in fluid overload. Results: The increased costs attributed to FFP-associated fluid overload for vitamin K antagonist reversal partly defrays the increased upfront cost of four-factor prothrombin complex concentrates. Discussion: FFP is commonly used to acutely reverse the effects of vitamin K antagonists. However, its use requires significant time for infusion, may lead to fluid overload, and is not fully effective in compete anticoagulation reversal. One alternative therapy for anticoagulant reversal is use of prothrombin complex concentrates, which are rapidly infused, are not associated with fluid overload, and are effective in complete reversal of coagulation measurements. This should be considered for patients with acute bleeding emergencies.

Keywords:

• anticoagulant
• bleeding
• cost–effectiveness
• fresh frozen plasma
• FP24
• plasma
• transfusion-associated circulatory overload
• vitamin K
• warfarin reversal

Financial & competing interests disclosure

The authors report early investigator-initiated and institutional sponsorship of this work by CSL Behring via University of Vermont. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Key issues

• We investigated the estimated economic downstream costs between administering fresh frozen plasma (FFP) versus four-factor prothrombin complex concentrates (4F-PCCs) for the rapid reversal of vitamin K antagonists.

• This study accounts for the estimated intensive care unit cost for patients who experience transfusion-associated circulatory overload (TACO) due to treatment with FFP.

• Although in the US the upfront cost is greater for administering 4F-PCC rather than FFP, the mitigation of potentially severe TACO reactions requiring patient admittance to intensive care units greatly reduces the estimated per patient effective cost.

• In Europe the upfront cost for FFP is even more expensive than 4F-PCC (approximately €800 vs. €546.70) hence accounting for TACO related ICU incidence with European figures makes the total estimated cost of administering 4F-PCC 50.7% less expensive than FFP for the rapid reversal of vitamin K antagonists.