Guidelines for the management of an elevated INR in adults
| Guidelines for Elevated INR in Adults WITHOUT Bleeding (1) | |||||||
| INR | Bleeding risk |
Warfarin | Vitamin K1 | FFP | PTX-VF | Measure INR | Comments |
| >therapeutic range but <5.0 |
Lower the dose or omit the next dose* |
Resume therapy at a lower dose when the INR approaches therapeutic range | |||||
| 5.0–9.0 |
Low |
Stop; consider reasons for elevated INR and patient-specific factors |
Within 24 hours | Resume warfarin at a reduced dose when the INR is in therapeutic range | |||
| High |
Give 1.0−2.0 mg oral or 0.5–1.0 mg intravenous |
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| >9.0 | Low | Stop | Give 2.5−5.0 mg oral or 1.0 mg intravenous | In 6−12 hours | Resume warfarin therapy at a reduced dose once INR is <5.0 | ||
| High | Give 1.0 mg intravenous | Consider 150–300 mL | Consider 25–50 IU/kg | ||||
|
Guidelines for Elevated INR in Adults WITH Bleeding (1) |
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| INR | Bleeding risk | Warfarin | Vitamin K1 | FFP | PTX-VF | Check INR |
|
| Any clinically significant bleeding where warfarin-induced coagulopathy is considered a contributing factor | Stop | Give vitamin K1 5.0–10.0 mg intravenous |
Give 150–300 mL |
Give 25–50 IU/kg | Assess patient continuously until INR is <5.0, and bleeding stops | ||
| If FFP is not available, give Vit K & PTX-VF | Give 25–50 IU/kg | ||||||
| Give 10–15 mL/kg | If PTX-VR is not available, give Vit K & FFP | ||||||
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Notes: *Dose reduction may not be necessary if the INR is only minimally above therapeutic range (up to 10%); INR = International Normalised Ratio; FFP = fresh frozen plasma; PTX-VF = Prothrombinex=VF |
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Reference
- Baker R, Couglin P, Gallus A, et al. Warfarin reversal: consensus guidelines, on behalf of the Australasian Society of Thrombosis and Haemostasis. MJA 2004;181(9):492–497.
