Warfarin Necrosis - Treatment and Prevention

Treatment and Prevention

The first element of treatment is usually to discontinue the offending drug, although there have been reports describing how the eruption evolved little after it had established in spite of continuing the medication. Vitamin K can be used to reverse the effects of coumarins, and heparin or its low molecular weight heparin (LMWH) can be used in an attempt to prevent further clotting. None of these suggested therapies have been studied in clinical trials.

Heparin and LMWH act by a different mechanism than warfarin, so these drugs can also be used to prevent clotting during the first few days of warfarin therapy and thus prevent warfarin necrosis (this is called 'bridging').

Because low levels of protein C are involved in the underlying mechanism, fresh frozen plasma or pure activated protein C has been used in this setting.

The necrotic skin areas are treated as in other conditions, sometimes healing spontaneously with or without scarring, sometimes going on to require surgical debridement or skin grafting. The risk of death is mainly related to underlying disorders for which anticoagulation is started (for example, recurrent pulmonary embolism).

Since the clot-promoting effects of coumarins are transitory, patients with protein C deficiency or previous warfarin necrosis can still be restarted on these drugs if appropriate measures are taken. These include gradual increase starting from low doses and supplemental administration of protein C (pure or from fresh frozen plasma).