Warfarin: Management of High INR

Question 1

Major bleed

Answer 1

• Stop Warfarin
• Give IV Vitamin K 5mg
• Prothrombin complex concentrate - FFP if PCC not available.

Question 2

INR >8 + Minor Bleeding

Answer 2

• Stop warfarin
• Give IV Vitamin K 1-3mg
• Repeat dose of vitamin K if INR still too high after 24 hours
• Restart warfarin when INR < 5.0

Question 3

INR > 8 + No Bleeding

Answer 3

• Stop Warfarin
• Give Vitamin K 1-5mg by mouth
• Repeat dose of Vitamin K if INR still too high after 24 hours.
• Restart when INR <5.0

Question 4

INR 5 to 8 + Minor Bleeding

Answer 4

• Stop warfarin
• Give IV Vitamin K 1-3mg
• Restart when INR < 5.0

Question 5

INR 5 to 8 + No Bleeding

Answer 5

• Withhold 1 or 2 doses of warfarin
• Reduce subsequent maintenance dose