title: Superwarfarin and glass ingestion with prolonged coagulopathy requiring high-dose vitamin K1 therapy.
abstract: A 23-year-old man was brought to the emergency department after eating four boxes of brodifacoum-containing rodenticide over a 4-day interval and pieces from approximately two bottles of glass over the previous 2 weeks. He was asymptomatic but his prothrombin time was markedly elevated with an international normalized ratio (INR) of 37.8. A plain abdominal film showed diffuse radiopaque foreign bodies, presumably glass, in the large and distal small intestines. Treatment for ingested glass consisted of stool softeners and bulk-forming laxatives. The patient developed mild gingival bleeding and received fresh frozen plasma (FFP) infusions and vitamin K1 orally. At a vitamin K1 dosage of 300 mg/day, the INR corrected to less than 2.0 and the patient was discharged taking that dosage. He returned 26 days later with hematuria and flank pain, and his INR was 189. He was administered FFP and packed red blood cells, and his vitamin K1 dosage was increased to 800 mg/day; his INR returned to baseline. Compliance with taking the vitamin K1, which required ingestion of 60-160 tablets/day, was a serious problem, requiring numerous follow-up calls and visits to the patient at home and work. At 5-month follow he was doing well. Compliance with large daily doses of vitamin K1 for treatment of "superwarfarin" ingestion may be poor because of the duration of treatment and large number of pills required. A more concentrated formulation may be advantageous for management of patients with brodifacoum poisoning.
authors.affiliation: California Poison Control System, San Francisco Division, Department of Clinical Pharmacy, University of California, San Francisco, San Francisco, California 94143-1369, USA.
authors.forename: Ben T
authors.initials: BT
authors.lastname: Tsutaoka
authors.forename: Michael
authors.initials: M
authors.lastname: Miller
authors.forename: Stacey M
authors.initials: SM
authors.lastname: Fung
authors.forename: Manish M
authors.initials: MM
authors.lastname: Patel
authors.forename: Kent R
authors.initials: KR
authors.lastname: Olson
mesh_terms: D015110:4-Hydroxycoumarins / Q000008:administration & dosage / Q000097:blood / Q000506:poisoning*; D000328:Adult; D001778:Blood Coagulation Disorders / Q000139:chemically induced* / Q000188:drug therapy*; D003679:Deglutition; D004349:Drug Packaging; D005898:Glass; D006801:Humans; D019934:International Normalized Ratio; D008297:Male; D010349:Patient Compliance; D012378:Rodenticides / Q000008:administration & dosage / Q000097:blood / Q000506:poisoning*; D010837:Vitamin K 1 / Q000008:administration & dosage / Q000493:pharmacokinetics / Q000627:therapeutic use*
chemical_list: D015110:4-Hydroxycoumarins; D012378:Rodenticides; D010837:Vitamin K 1; C013418:bromfenacoum