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 35 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