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.