Recombinant Factor 7 (Factor 7) is a synthetic version of the naturally circulating coagulation enzyme. Factor 7 exerts a potent hemostatic effect. Originally, it was developed for the treatment of hemophilia. Factor 7 has been used off label to stop bleeding in trauma patients and to correct coagulopathy in patient taking anticoagulants (Warfarin aka Coumadin).

I like to think of Factor 7 as tPA (thrombolytic) with the reverse action. It is a very potent medicine when used appropriately, yet the side effects could be devastating. With a potent procoagulant action, Factor 7 can cause thrombosis (clotting) in the cerebral arteries causing strokes and coronary arteries causing myocardial infarction. Thrombosis in the mesenteric and peripheral arteries was also reported.

The use of factor 7 for patients with blunt trauma showed reduced blood transfusion and massive transfusion requirements. There was no benefit when Factor 7 was used for penetrating trauma. In both groups of patients there was no mortality benefit.

In my personal experience, I used Factor 7 in an elderly patient with a massive blunt chest injury and uncontrolled bleeding. We were able to control the bleeding, yet the patient developed a disabling stroke attributed to Factor 7.

The application of Factor 7 for the treatment of intracerebral hemorrhage (ICH) is controversial as well. One study found that the use of Factor 7 may limit the progression of hemorrhage, yet there was no improve in survival or functional outcome. Factor 7 in this study was used regardless of the pre-administration coagulation profile. The patients not taking anticoagulants prior to Factor 7 administration may have limited benefit and potentially develop thrombotic complications, offsetting the beneficial effects of Factor 7.

A recent small study out of Texas published in the Journal of Trauma looked at the use of Factor 7 for patients with a traumatic brain injury and preexisting coagulopathy. The study indicates that when used in the appropriate setting (administered to coagulopathic patients with a head injury), Factor 7 was associated with an effective correction of coagulopathy, decreased transfusion rates with blood and plasma, as well as savings associated with the reduction in blood transfusions.

The fact that the cost savings were documented in this study is quite remarkable. Factor 7 is considered very expensive. The cost of 1mg is about 1000 dollars. I have been using Factor 7 in doses ranging from 90 to 120mcg per kilogram. A 70kg patient will get a dose of 7mg on average, costing about 7000 dollars. This is not cheap but any measure.

Having reviewed the literature and having some experience with using Factor 7 I came to the conclusion that Factor 7 has it’s role in the Intensive Care Unit primarily as a rapid coagulopathy reversal agent to facilitate the management of massive bleeding or life-threatening intracerebral hemorrhage.

I have attended multiple meetings in the hospital to facilitate the process of rapid coagulopathy correction with fresh frozen plasma in the patients with intracerebral hemorrhage. At the end of the day, I found that nothing beats Factor 7 when you need to reverse coagulopathy. The same goes for patients on Coumadin with traumatic subdural/epidural hematomas that require urgent craniotomy. In these circumstances it’s not just about saving money by transfusing less blood products, it’s about saving lives.