Recombinant factor VIIa is approved for bleeding episodes in hemophilia A and B patients who have circulating inhibitors to factor VIII and IX, respectively. Most of its use, however, is probably for a variety of off label indications including life threatening bleeding in patients on warfarin or with liver failure. The 2004 ACCP guidelines on antithrombotic therapy, for example, support its use in patients on warfarin with life threatening bleeding.
These off label uses, at times controversial, have created challenges for hospitals at the institutional level due to cost concerns. This paper from the American Journal of Health System Pharmacy describes how one academic institution, the University of Virginia Health System, addressed the problem. Evidence for various off label uses is cited and proposed guidelines for on and off label uses are provided.