HOW TO MANAGE HIGH INRs IN WARFARIN PATIENTS

Elevated INR , no significant bleeding

hhhh INR <5.0 Lower /hold warfarin dose

INR >5.0 and <9.0 Hold doses of warfarin Or Hold a dose of warfarin and give vitamin K12.5mg PO Or Give vitamin K<5mg PO if more rapid INR reversal is required(patient requires surgery) Additional vitamin K1-2.5mg PO can be given if INR remains high

INR >9.0 Hold warfarin therapy and give vitamin K2.5-5mg PO Additional vitamin K may be given if INR remains elevated

+/- Lower warfarin dosage if INR is only minimally elevated

Elevated INR, serious bleeding

Serious bleeding
Hold warfarin therapy and give vitamin K 10mg by slow IV infusion, supplemented with FFP,PCC or rVIIa Vitamin K may be repeated every 12 hours depending on INR and patient condition

Life threatening bleeding

Hold warfarin therapy and give FFP,PCC or rVIIa supplemented with vitamin K 10mg by slow IV infusion

Repeat above ,if necessary ,depending on INR and patient condition

FFP FRESH FROZEN PLASMA. PCC-PROTHROMBIN CONMPLEX CONCENTRATE,rVIIa-recombinant factor VIIa