Resistance to oral vitamin K for reversal of overanticoagulation during Crohn's disease relapse

Abstract

Objective: The purpose of this case report is to describe oral vitamin K resistance in a patient with concomitant Crohn's disease (CD) relapse and supratherapeutic anticoagulation. Additionally, a literature review was conducted to explore the mechanism and supporting evidence for poor response to oral vitamin K during CD relapse.

Case report: A 36 year-old female presented with an elevated International Normalized Ratio (INR) of 7.8 during a relapse of CD including symptoms of severe, persistent diarrhea and reduced appetite. For excessive anticoagulation, initial management consisted of withholding warfarin for seven days, administering vitamin K in a total dose of 10 mg orally and 1 mg intravenously. One week later, the INR remained elevated at 8.09. Subcutaneous vitamin K, in a dose of 5 mg, was administered on day eight, and the INR was reduced to a subtherapeutic result of 1.2 on day eleven.

Discussion: The case report illustrates a poor response to recommended and repeated doses of oral vitamin K and a single, small dose of intravenous vitamin K during CD relapse. However, the patient responded favorably to vitamin K by the subcutaneous route. Current literature and consensus guidelines recommend the oral route of vitamin K as first-line management of overanticoagulation due to warfarin. Present data supports that patients with inflammatory bowel disease including CD have a greater incidence of vitamin K deficiency and malabsorption, and this is likely due to multiple pathological mechanisms.

Conclusions: Based on this case report, treatment of overanticoagulation in patients with CD relapse should include aggressive management, close monitoring, and consideration of an alternative, parenteral route of vitamin K administration rather than by the oral route due to potential for poor absorption.