Prothrombinex-VF
Aka. 3-Factor Prothrombin Complex
Please note in 2024 in Australia, Prothrombinex will be replaced by Beriplex P/N and eventually (by 2025) Beriplex AU, a FOUR Factor concentrate. Please see the appropriate page.
DESCRIPTION
- Concentrated human factor II, IX and X (prothrombin complex)
INDICATIONS
- Congenital factor II, IX or X (Haemophilia B) deficiency when a concentrated single-factor product is not available
- Treatment or perioperative prophylaxis of bleeding for patients on vitamin K (e.g. warfarin) antagonist or vitamin K antagonist overdose
- Because my ROTEM algorithm told me to, where the EXTEM CT>90s and FIBTEM A5>10mm or the EXTEM CT >140s and FIBTEM A5<10mm (please refer to your local guidelines)
ADMINISTRATION / DOSING
- Intravenous (IV)
- Dosing:
- Generally starting dose for active haemorrhage: 10-20 IU/kg (suggested by institutional ROTEM/TEG algorithms)
- Warfarin reversal for bleeding or surgery: 25-50 IU/kg
- If INR >10, may require repeat dosing
- Please refer to dosing table below for breakdown of dosing
- For congenital deficiency of Factor IX (Haemophilia B):
- Please see dosing table below
- NOTE: concentrated Factor IX is superior to prothrombinex for the same, only administer if Factor IX is not available
- **If unsure, please speak to your local haematology department**
- Administration:
- Administer as a slow IV push
- Not compatible with any other fluid nor any other blood product
- Reconstitution guideline below
- Need to allow the vials to come to room temperature prior to reconstitution
PREPARATION
- Manufactured from human plasma (Prothrombinex-VF made from Australian blood donors with donations supplied through LifeBlood)
- Heat treated (+80oC for 72 hours) for viral inactivation and nanofiltration for virus removal
- It is then lipophilised (aka. freeze-dried, or cryodesiccated)
PHARMACEUTICS
- Presentation:
- Single-dose glass vial of Prothrombinex®-VF with a rubber stopper closed with an aluminium seal
- One glass vial of 20 mL water for injection
- One Mix2VialTM filter transfer set
- Contents:
- 500 IU of Factor IX
- ~500 IU of Factor II
- ~500 IU of Factor X
- Excipients:
- Human plasma proteins <500 mg
- Antithrombin III 25 IU
- Heparin Sodium 192 IU
- Sodium 112 mg
- Phosphate 65 mg
- Citrate 180 mg
- Chloride 27 mg
- Storage:
- Temperatures of 2-8oC and is stable for up to 36 months
- Can be stored below 25oC and is stable up to 6 months
- Must be administered immediately after reconstitution
GROUP / CROSSMATCH
- Not required
ADVERSE EFFECTS
- Thromboembolic episodes including MI, PE, DVT and arterial thrombosis
- Allergic reaction: anaphylaxis, dyspnoea, rash
- Chills, nausea, vomiting
- Risk of infectious disease transmission such as: CJD, HIV, Hep B and C
LOCATION OF ACTION
MECHANISM OF ACTION
- Coagulation factors II, VII, IX and X are all synthesised within the liver and dependent on vitamin K, and are commonly referred to as prothrombin complex
- Factor VII is the zymogen of the active serine protease factor VIIa by which the extrinsic pathway of blood coagulation is initiated
- Tissue factor-factor VIIa complex activates factors X and IX –> Factor IXa and Xa –> prothrombin activated and transformed into thrombin. Thrombin + Fibrinogen –> Fibrin –> clot formation
- Onset:
- Peak effect within 5 mins
- Elimination half-life of factors:
- Factor II: 60 h
- Factor VII: 4.2 h
- Factor IX: 17 h
- Factor X: 31 h
CONTRAINDICATIONS
- Known hypersensitivity / anaphylaxis reactions to this product or other concentrated fractionated plasma products
ADVANTAGES AND DISADVANTAGES TO FFP
Advantages
- Small volume (20 mL vs ~300 mL), equally, does not provide volume during resuscitation
- Readily available
- Reliable reversal
- Avoids complications of FFP such as immune reaction, TRALI, fever, infection risk
- No time delay for unit thawing
- No crossmatch required
Disadvantages
- Roughly double the cost of a unit of FFP (1 unit of FFP ~500 IU of PTx)
- Cost of 500 IU of PTx: AUD$305.98
- Cost of 1 unit of FFP: AUD$152.37
RECONSTITUTION TIPS
DO NOT shake when the water for injection has been added, otherwise you will end up with a foamy mess (like teicoplanin, you only ever do it once)
- You will need, in addition to the package contents, a 20 mL luer-lock syringe, and a sterile alcohol wipe (or equivalent)
- You will also need a decent amount of bench space if you are reconstituting more than 500 units
WARFARIN REVERSAL DOSING TABLE
PROTHROMBINEX IN HAEMOPHILIA B (Factor IX Deficiency)
References and Links
CCC Transfusion Series
Blood Products: Cryoprecipitate, Fresh Frozen Plasma (FFP), Platelets, Red Cells (RBCs)
>>> Factor Concentrates: Prothrombinex, Factor VIIa, Fibrinogen Concentrate
Reversal Agents:
>>> Rivaroxaban / Apixaban / Enoxaparin: Andexanet Alfa, Rivaroxaban and Bleeding
>>> Dabigatran: Idarucuzimab, Dabigatran and bleeding
>>> Heparin: Protamine
>>> Warfarin: Vitamin K, FFP, PTx, Warfarin Refersal, Warfarin Toxicity
Testing: Coagulation Studies, TEG / ROTEM (Thromboelastography), Platelet function assays
Conditions: Acute Coagulopathy of Trauma, Disseminated Intravascular Coagulation (DIC), Massive Blood Loss
General Topics: Blood Bank, Blood Conservation Strategies, Blood Product Compatibilities, Blood Transfusion Risks, Massive Transfusion Protocol (MTP), Modifications to Blood Components, Procedures and Coagulopathy, Storage Lesions, TRALI, Transfusion Literature, Transfusion Reactions
CCC Pharmacology Series
Respiratory: Bosentan, Delivery of B2 Agonists in Intubated Patients, Nitric Oxide, Oxygen, Prostacyclin, Sildenafil
Cardiovascular: Adenosine, Adrenaline (Epinephrine), Amiodarone, Classification of Vasoactive drugs, Clevidipine, Digoxin, Dobutamine, Dopamine, Levosimendan, Levosimendan vs Dobutamine, Milrinone, Noradrenaline, Phenylephrine, Sodium Nitroprusside (SNiP), Sotalol, Vasopressin
Neurological: Dexmedetomidine, Ketamine, Levetiracetam, Lignocaine, Lithium, Midazolam, Physostigmine, Propofol, Sodium Valproate, Sugammadex, Thiopentone
Endocrine: Desmopressin, Glucagon Therapy, Medications and Thyroid Function
Gastrointestinal: Octreotide, Omeprazole, Ranitidine, Sucralfate, Terlipressin
Genitourinary: Furosemide, Mannitol, Spironolactone
Haematological: Activated Protein C, Alteplase, Aprotinin, Aspirin, Clopidogrel, Dipyridamole, DOACs, Factor VIIa, Heparin, LMW Heparin, Protamine, Prothrombinex, Tenecteplase, Tirofiban, Tranexamic Acid (TXA), Warfarin
Antimicrobial: Antimicrobial Dosing and Kill Characteristics, Benzylpenicillin, Ceftriaxone, Ciprofloxacin, Co-trimoxazole / Bactrim, Fluconazole, Gentamicin, Imipenem, Linezolid, Meropenem, Piperacillin-Tazobactam, Rifampicin, Vancomycin
Analgesic: Alfentanil, Celecoxib, COX II Inhibitors, Ketamine, Lignocaine, Morphine, NSAIDs, Opioids, Paracetamol (Acetaminophen), Paracetamol in Critical Illness, Tramadol
Miscellaneous: Activated Charcoal, Adverse Drug Reactions, Alkali Therapies, Drug Absorption in Critical Illness, Drug Infusion Doses, Epidural Complications, Epidural vs Opioids in Rib Fractures, Magnesium, Methylene Blue, Pharmacology and Critical Illness, PK and Obesity, PK and ECMO, Sodium Bicarbonate Use, Statins in Critical Illness, Therapeutic Drug Monitoring, Weights in Pharmacology
Toxicology: Digibind, Flumazenil, Glucagon Therapy, Intralipid, N-Acetylcysteine, Naloxone, Propofol Infusion Syndrome
References
- CSL Behring. (2020, March 23). Product Information. Retrieved January 27, 2023, from https://prothrombinex.cslbehring.com.au/system/files/pdf/2021-07/ProthrombinexVF-AU-PI-1400.pdf
- CSL Behring. (2021, February). PROTHROMBINEX®-VF RECONSTITUTION. Retrieved January 27, 2023, from https://prothrombinex.cslbehring.com.au/system/files/pdf/2021-04/prothombinex-updates-2021-A5-2pp-Instruction-Card.pdf
- CSL Behring. (2019, June). Consensus Guidelines Update for Warfarin Reversal. Retrieved January 27, 2023, from https://prothrombinex.cslbehring.com.au/warfarin-reversal-guidelines
- D, J. (2007, April 22). File:coagulation full.svg. Retrieved January 17, 2023, from https://commons.wikimedia.org/wiki/File:Coagulation_full.svg
- National Blood Authority Australia. (2023, January 01). What blood products are supplied – national product price list. Retrieved January 18, 2023, from https://www.blood.gov.au/national-product-price-list
Critical Care
Compendium
ICU Advanced Trainee BMedSci [UoN], BMed [UoN], MMed(CritCare) [USyd] from a broadacre farm who found himself in a quaternary metropolitan ICU. Always trying to make medical education more interesting and appropriately targeted; pre-hospital and retrieval curious; passionate about equitable access to healthcare; looking forward to a future life in regional Australia. Student of LITFL.