ELEVATED INR (reversal) Definition: Reversal of anticoagulation of Coumadin (Warfarin) as measured by INR.
INR	Clinical Situation	Action
> 3 < 5	No bleeding and no risk bleeding	Omit 1-2 doses Coumadin; INR in 2 days; restart Coumadin at lower dose at INR < or = 3
5-9	No bleeding and no risk bleeding	Omit 2-3 doses Coumadin; INR in 2 days; restart Coumadin at lower dose at INR < or = 3
5-9	Rapid reversal for surgery	Give Vitamin K 2-4 mg PO, repeat in 24 hours if INR >5 – discuss with physician colleague – may need FFP depending on surgical schedule
5-9	Minor bleeding or increased risk of bleeding	Stop Coumadin; give Vitamin K 1-2.5 mg PO; repeat INR in 24hours; discuss with physician colleague before restart
> 9	No bleeding and low risk of bleeding or minor bleeding [non-urgent reversal]	Stop Coumadin; give Vitamin K 3–5 mg PO- repeat INR in 24 hours; then give Vitamin K 3 mg PO if INR > 6; repeat INR in 24 hours; discuss with physician colleague before restart
> 9	Serious bleeding	To ER
References: Bushwick, BM: Practical advice on prescribing Warfarin on The Clinical Advisor, June 2004, 49-56. Jacobs, LG: The Use of Oral Anticoagulants, AGS Clinical Practice Guidelines in JAGS 48:224-227, 2000. Lubetsky, A. et al: Comparison of Oral vs Intravenous Phytonadione (Vitamin K1 ) in Patients With Excessive Anticoagulation in Arch Intern Med, Vol. 163, N0. 10, 2003, 2469-2473.

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Revised 07/04