Condition | Description |
---|---|
INR above therapeutic range but <5.0; no significant bleeding | Lower dose or omit dose, monitor more frequently and resume at lower dose when INR is therapeutic; if only minimally above the therapeutic range, no dose reduction may be required (Grade 1C) |
INR ≥ 5.0 but <9.0; no significant bleeding | Omit next one or two doses, monitor more frequently and resume at an appropriately adjusted dose when INR is in the therapeutic range. Alternatively, omit dose and give vitamin K (1 to 2 mg orally), particularly if at increased risk of bleeding. If more rapid reversal is required because the patient requires urgent surgery, vitamin K (≤ 5 mg orally) can be given with the expectation that a reduction of the INR will occur in 24 h. If the INR is still high, additional vitamin K (1 to 2 mg orally) can be given (Grade 2C) |
INR ≥ 9.0; no significant bleeding | Hold warfarin therapy and give higher dose of vitamin K (2.5 to 5 mg orally) with the expectation that the INR will be reduced substantially in 24 to 48 h (Grade 1B). Monitor more frequently and use additional vitamin K if necessary. Resume therapy at an appropriately adjusted dose when the INR is therapeutic |
Serious bleeding at any elevation of INR | Hold warfarin therapy and give vitamin K (10 mg by slow intravenous infusion), supplemented with FFP, PCC or rFVIIa, depending on the urgency of the situation; vitamin K can be repeated every 12 hours (Grade 1C) |
Life-threatening bleeding | Hold warfarin therapy and give FFP, PCC or rFVIIa supplemented with vitamin K (10 mg by slow intravenous infusion); repeat if necessary, depending on INR (Grade 1C) |