<< Back to News

7/25/19 MC HOSP Emergent Reversal of Anticoagulants - FEIBA Updates and Clarifications
July 29, 2019

From: "Monroe Crawley" <monroe.crawley@hhsys.org>
To: "Pharmacists" <grp_allpharm@hhsys.org>
Sent: Thursday, July 25, 2019 7:22:13 PM
Subject: HOSP Emergent Reversal of Anticoagulants - FEIBA Updates and Clarifications

Pharmacists,

As you all know, we have been using FEIBA for the reversal of anticoagulants in patients with life-threatening bleeding. We have found some areas for improvement in our current system,  and have made a few changes to the PowerPlan. Here are some reminders and clarifications to help improve utilization of this therapy:

1. Look at the PowerPlan in PowerChart

• The order should be initiated under HOSP Emergent Reversal of Anticoagulants

2. 
   What anticoagulant was the patient taking that needs to be reversed?

• Previously, the dose would be pre-populated upon selection. Now, selecting FEIBA will prompt the prescriber to select a dose for the specific indication.
• Check to ensure that the dose ordered corresponds with the anticoagulant we are reversing.
• Warfarin Reversal - FEIBA doses should be 500 units or 1,000 units dependent on INR (not dependent on indication)
• NOAC (apixaban, rivaroxaban, etc.) Reversal - FEIBA doses should be 25 units/kg, 30 units/kg, or 50 units/kg depending on the type of hemorrhage (see indication below)

3. 
   What type of hemorrhage are we treating?

• Warfarin Reversal - FEIBA dose is NOT dependent on indication (dependent on INR only)
• NOAC Reversal
• Check to ensure that the dose ordered corresponds with the type of hemorrhage we are treating.
• Intracranial hemorrhage (ICH) - 25 units/kg or 50 units/kg (physician discretion)
• Any other bleeding - 30 units/kg

4. Has the patient received Fresh Frozen Plasma (FFP)?

• Because FEIBA and FFP contain high levels of coagulation factors, the combination of these agents can substantially increase the risk of thrombosis. 
• Current expert opinion recommends against the use of FFP for bleeding associated with Factor Xa Inhibitors like apixaban and rivaroxaban.** 
• Check to ensure FFP has NOT been administered.
• Generally, this will be found in the orders section under HOSP Blood Products Transfuse Now. 
• However, not all FFP administration will be charted prior to orders for FEIBA. The best way to assess whether FFP has been given is by calling the RN. 
• If a patient has already received FFP, they should NOT receive FEIBA for at least 4 hours.
• If after 4 hours, the patient is observed to still have substantial bleeding, FEIBA can be given

**Kaatz S, Kouides PA, Garcia DA, Spyropolous AC, Crowther M, Douketis JD, Chan AK, James A, Moll S, Ortel TL, Van Cott EM. Guidance on the emergent reversal of oral thrombin and factor Xa inhibitors. American journal of hematology. 2012 May;87(S1):S141-5

The diluent volumes for reconstituting FEIBA will now appear in the product selection phase of the order within Med Manager. This should help with determining the total volume for doses < 2,500 units. If other issues/questions arise, please feel free to contact me. Thank you.

Sincerely,

1. Monroe Crawley, Pharm.D., BCPS

Huntsville Hospital, Department of Pharmacy
101 Sivley Road, Huntsville, AL 35801
monroe.crawley@hhsys.org