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• W2016390561 abstract "M Crowther and colleagues (Nov 4, p 1551)1Crowther MA Julian J McCarty D et al.Treatment of warfarin-associated coagulopathy with oral vitamin K: a randomised controlled trial.Lancet. 2000; 356: 1551-1553Summary Full Text Full Text PDF PubMed Scopus (162) Google Scholar recommend routine use of low dose oral vitamin K to rapidly lower international normalised ratios (INR) of 4·5–10·0. Difficulties with warfarin coagulopathy are frequently encountered in patients treated with oral anticoagulation. For those with an INR above 10, there is agreement on vitamin K use because of the high risk of bleeding,2Hirsch J Dalen JE Anderson DR et al.Oral anticoagulants; mechanism of action, clinical effectiveness, and optimal therapeutic range.Chest. 1998; 114: 445S-469SSummary Full Text Full Text PDF PubMed Google Scholar but for the management of those receiving warfarin with INR value of 4·5–10·0 there are no recognised standards. Crowther and colleagues state that a symptomless moderate increase of INR is frequently associated with serious bleeding, and that low dose oral vitamin K does not raise the risk of thrombosis and is more effective than placebo for rapid lowering of raised INR values, as shown by their results. For patients on warfarin with a symptomless increase in the INR to between 4·5 and 10, the difficulty is to rapidly lower the INR and keep it in the therapeutic range. We were concerned with the significantly higher number of patients in the vitamin K group who had INR values lower than 1·5. Crowther and colleagues do not discuss this point. During the 5 days after treatment was given, 13 of 141 patient-days in the placebo group and 24 of 121 in the vitamin K group were at this infra-therapeutic level. The investigators are reassuring about the absence of risks of thromboembolic events attributable to rapid lowering of the INR after vitamin K treatment. However, their study, which included a small number of patients (44 in the placebo group, 45 in the vitamin K group), was probably not powerful enough to detect an increase in the risk of thrombosis in patients whose INR fell to lower than 1·5. Moreover, they state that other studies that have shown that low dose vitamin K was safe were non-randomised, small, or did not use a clinically applicable protocol.3Crowther MA Donovan D Harrison L McGinnis J Ginsberg J Low-dose oral vitamin K reliably reverses over-anticoagulation due to warfarin.Thromb Haemost. 1998; 79: 1116-1118PubMed Google Scholar, 4Pengo V Banzato A Garelli E Zasso A Biasiolo A Reversal of excessive effects of regular anticoagulation: low dose of phytonadione (vitamin K) compared with warfarin discontinuation.Blood Coagul Fibrinolysis. 1993; 4: 739-741Crossref PubMed Scopus (80) Google Scholar, 5Weibert RT Le DT Kayser SR Rapaport SI Correction of excessive anticoagulation with low-dose oral vitamin K1.Ann Intern Med. 1997; 126: 959-962Crossref PubMed Scopus (116) Google Scholar Medical decisions should be individually based. The benefit of preventing serious bleeding has to be balanced with the individual's risk of thrombosis induced by the excessive correction of the INR by low-dose oral vitamin K. For example, in a patient with distal vein thrombosis whose INR value is 9, the risk of serious bleeding justifies the use of oral low-dose vitamin K and outweighs the risk of thrombosis. In a patient with a mechanical heart valve whose INR is 5, however, thrombosis could lead to devastating disease and might not be outweighed by the risk of serious bleeding. These issues must be addressed before recommending low-dose oral vitamin K for any patients with a symptomless increase in the INR to between 4·5 and 10. Otherwise, clinicians may (correctly) continue not to reverse with vitamin K any moderate symptomless increase of the INR in all patients. Vitamin K in anticoagulation therapyAuthors' reply Full-Text PDF" @default.
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• W2016390561 title "Vitamin K in anticoagulation therapy" @default.
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• W2016390561 doi "https://doi.org/10.1016/s0140-6736(05)71429-x" @default.
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