(956) Phytonadione Utilization and the Risk of Bleeding in Chronic Liver Disease

Introduction: Chronic liver disease patients often receive phytonadione for correction of elevated international normalized ratios (INRs), but there is limited evidence to support this practice. The purpose of this study was to determine the safety and efficacy of phytonadione in patients with an elevated INR secondary to chronic liver disease without active bleeding.

Methods: This retrospective chart review compared hospitalized adult patients from January 2015 through November 2022 with a diagnosis of chronic liver disease, a baseline INR of 1.2-1.9, and without active bleeding who did or did not receive phytonadione. The primary outcome was the incidence of new bleeding, which was defined as overt bleeding noted in provider documentation in the electronic medical record, bleeding on imaging, an event requiring at least two units of packed red blood cells, or a diagnosis of new bleeding on the discharge summary. The incidence of thrombosis, defined as new venous thromboembolism, myocardial infarction, and ischemic stroke as well as change in INR were also evaluated.

Results: A total of 133 patients were included, of which 46 received phytonadione (mean 2.46 doses, mean dose 7.95 mg, 72.74% intravenously). Most had unspecified cirrhosis of the liver (49.62%) followed by alcoholic cirrhosis of the liver (29.32% with ascites and 17.29% without ascites). At baseline, the phytonadione patients had a higher INR (1.46 vs 1.68, p< 0.0001) and Child-Pugh Score (8.70 vs 9.93, p=0.0003). There was no difference in the incidences of new bleeding (9.20% vs 13.04%, p=0.492) or thrombosis (3.45% vs 0%, p=0.203) between the control and phytonadione groups. After phytonadione administration, there was no change in INR, while INR increased by 0.24 in the control group (p=0.025).

Conclusions: In chronic liver disease patients who were not bleeding, phytonadione did not reduce INR or the incidence of new bleeding. However, given the similar incidence of thrombosis, it may be safe. Future research could continue to focus on non-bleeding patients with higher baseline INRs as well as explore the utility of viscoelastic testing and the use of coagulation markers other than INR to better assess the risk of bleeding in chronic liver disease patients.