Elevated INR and No Bleeding
Clinical Setting |
Recommendation |
INR higher than the therapeutic range but <4.5 |
·
Lower or omit next dose of Warfarin
·
Resume Warfarin at a lower dose when the INR approaches
the therapeutic range
·
If the INR is only minimally above the therapeutic range
then a dose reduction is generally not necessary. |
INR 4.5 – 10.0 and no bleeding |
·
Cease Warfarin therapy
·
Vitamin K is usually unnecessary
·
Measure INR within 24 hrs
·
Resume Warfarin at a lower dose when the INR approaches
the therapeutic range
If bleeding risk high
·
Consider vitamin K 1.0 – 2.0 mg orally or 0.5 – 1.0 mg
i.v.
|
INR > 10.0 and no bleeding |
·
Cease Warfarin therapy
·
Administer Vitamin K 3.0 – 5.0 mg orally
·
Measure INR within 12 - 24 hrs. Closely monitor INR daily
·
Resume Warfarin at a lower dose when the INR approaches
the therapeutic range
If bleeding risk high
·
Consider Prothrombinex-VF 15-30 IU/kg i.v.
|
Tran HA, Chunilal SD, Harper PL, et al. An update of consensus guidelines for warfarin reversal. Med J Aust 2013; 198 (4): 198-199. © Copyright 2013 The Medical Journal of Australia - reproduced with permission.
Oral vitamin K has not been shown to reduce the
risk of bleeding in patients with an INR up to 10.0 with no risk factors for
bleeding.
Vitamin K should be considered in patients with
risk factors for bleeding including:
·
Bleeding within the previous 4 weeks
·
Surgery within the previous 2 weeks
·
Liver disease
·
Concurrent antiplatelet therapy
·
Platelet count less than 50 x 109/l.
·
An outpatient study in patients with an INR
>10.0 reported a low rate of bleeding when patients received 2.5mg of oral
vitamin K.