Data for VKAs other than warfarin are limited, reducing confidence in this recommendation for patients treated with phenprocoumon, which has a longer half-life than warfarin. The panel identified the following additional research questions. (1) Is withholding VKA alone a safe and effective option for patients presenting with INRs of .10.0 in the absence of bleeding? (2) What is the minimum amount of oral vitamin K required to reverse the hypoprothrombinemic effect of VKA? (3) Can dietary sources of vitamin K (eg, broccoli, spinach, etc) be used to manage excessive VKA anticoagulation in nonbleeding patients? Question: For patients with life-threatening bleeding during VKA treatment of VTE, should 4-factor PCC vs FFP be used, in addition to cessation of VKA and IV vitamin K? For patients with life-threatening bleeding during VKA treatment of VTE who have an elevated INR, the ASH guideline panel suggests using 4-factor PCC rather than FFP, in addition to cessation of VKA and IV vitamin K (conditional recommendation based on very low certainty in the evidence about effects ). Summary of the evidence. We included eligible studies from the most recent systematic review for patients presenting with VKA-associated bleeding who received PCC vs FFP in addition to vitamin K and temporary cessation of VKA.182 The search was updated from 2016 onward, yielding 3 eligible RCTs.183-185 Additional studies included in the systematic review proved ineligible because patients needed VKA reversal for urgent or semiurgent surgery and not because of bleeding. 