Bleeding associated with acquired factor V inhibitor in a patient on warfarin treated successfully with prednisolone

An 85-year-old man on warfarin for atrial fibrillation presented with skin bleeding. International normalised ratio (INR) and activated partial thromboplastin time (APTT) were elevated and did not correct even after warfarin reversal with vitamin K, prothrombin complex concentrate (PCC) and fresh frozen plasma. Mixing coagulation studies with normal plasma suggested the presence of an inhibitor rather than the multiple coagulation factor deficiencies expected with warfarin. Assays of the common-pathway coagulation factors revealed factor V concentration <2% with inhibitor level elevated to 11 Bethesda units. The bleeding resolved following a course of corticosteroids. Coagulation studies and factor V level returned to normal along with resolution of the inhibitor. We report the case of the diagnostic dilemma posed and successful therapy implemented despite the limited evidence-based data being available for the treatment of this rare condition.

Latest news from Eyes on Evidence

 Issue 51 – July 2013
This month in Eyes on Evidence
General health checks in adults

A Cochrane review suggests that general health checks are not associated with reductions in mortality or morbidity.

Hand eczema in healthcare workers 

A randomised controlled trial indicates that accurate diagnosis of hand eczema and a preventive education intervention in healthcare workers may improve symptoms and quality of life.
A systematic review suggests a lack of clear evidence for a relationship between negative mood and the premenstrual phase in the general population.
Adherence to a warfarin dosing algorithm by clinicians treating people with atrial fibrillation may be associated with improved coagulation control and clinical outcomes.
A retrospective observational study indicates that although short-term trends indicate a decline, longer-term data for 1971 to 2011 show a small increase in new medicine launches.
We highlight 2 new examples from the QIPP collection demonstrating how NHS organisations have implemented new local practices that have both cut costs and improved quality.
NICE has recently published Evidence Updates on:
  • Depression in children and young people
  • Surgical site infection

BMJ Learning module: Club Drugs

Extract from BMJ Learning

A proliferation of new and often unknown recreational drugs has entered the UK market. These so called “club drugs” or “legal highs” are wide ranging but fit broadly into five categories: amphetamine related, GHB, canabinoid substitutes, ketamine, and plant based substances.

In a new audio module, the background of the drugs is discussed, how they are being used, and the associated harms. Click on the link to listen today:

Club drugs and legal highs
 
Additional popular modules on haematology for you to complete. They give an important update on a range of common dilemmas:

Anaemia in old age: common presentations
 
Malaria: an update on management in adults
 
How to reverse the effects of warfarin in hospital practice: an update

Chronic lymphocytic leukaemia

News from NICE

Help with identifying meningitis in children and young people
NICE?s latest quality standard on bacterial meningitis in children and young people can help GPs and other primary care professionals spot early signs and symptoms of the condition.
July 25, 2012
New treatment for blood clots approved by NICE
Patients with blood clots can be now be offered rivaroxaban as an alternative to warfarin for the treatment of blood clots following latest guidance from NICE.
July 25, 2012
First set of local government briefings launch
Tobacco, physical activity and workplace health are the topics covered in NICE?s first set of local government public health briefings.
July 25, 2012
NICE to assess high cost drugs for rare conditions
NICE will take on the role of assessing very high cost drugs for people who suffer with rare conditions, under the Health and Social Care Act 2012.
July 20, 2012
Healthy diet and exercise key to reducing the risk of type 2 diabetes
Simple lifestyle changes, such as increased physical activity or eating more healthily, can prevent or delay type 2 diabetes, says NICE.
July 12, 2012

Warfarin v Aspirin – new research published

“Aspirin could be as effective as more expensive drugs for heart failure patients with a normal heart rhythm, according to researchers.

Their study on more than 2,000 patients, published in the New England Journal of Medicine, said aspirin was as effective as the commonly prescribed drug warfarin.   It said each drug had risks, but they had similar benefits overall.” (BBC News)

Read the full findings at http://www.nejm.org/doi/pdf/10.1056/NEJMe1202504

“The benefit of warfarin in reducing the rate of ischemic stroke was offset by an increase in the rate of major bleeding (1.78 events per 100 patient-years with warfarin vs. 0.87 events per 100 patient-years with aspirin, P<0.001; number needed to harm, 110), although there was no excess of intracerebral bleeding events (0.12 events per 100 patient-years with warfarin and 0.05 events per 100 patient-years with aspirin, P = 0.35).”

King’s Fund: Toolkit for care of frail older people

Royal College of Physicians

Toolkit for improving care for frail older people
This is the third in a series of acute care toolkits which aims to improve the care of the frail older patient. The toolkit, produced in collaboration with the British Geriatrics Society, recommends procedures for both initial assessment on admission and later Comprehensive Geriatric Assessment.

Older people make up 60–70% of hospital inpatients, and most are admitted through an Acute Medical Unit (AMU), making this a key area in which care for older people can be influenced. It can be difficult for doctors to assess frail older patients as they can often arrive at hospital with multiple symptoms or conditions which can make it difficult to deduce the true cause of the admission.

The new six-page toolkit, produced in collaboration with the British Geriatrics Society, recommends procedures for both initial assessment on admission and later Comprehensive Geriatric Assessment (CGA).