Guidelines for the management of an elevated INR in adults

Management of patients on Warfarin therapy with high INR in Adults WITHOUT Bleeding (1)

Warfarin
Reduce or omit the next dose*
Comments
Resume warfarin at reduced dose when INR reaches therapeutic range.
Warfarin
Stop
Measure INR
Within 24 hours
Comments
Resume warfarin at reduced dose when INR reaches therapeutic range.
Warfarin
Stop
Vitamin K1
Give 1.0−2.0 mg oral or
0.5–1.0 mg intravenous
Measure INR
Within 24 hours
Comments
Resume warfarin at reduced dose when INR reaches therapeutic range.
Warfarin
Stop
Vitamin K1
Give 3.0−5.0 mg oral or intravenous
Measure INR
Within 12 hours
Comments
Resume warfarin at reduced dose when INR reaches therapeutic range.
Warfarin
Stop
Vitamin K1
Give 3.0−5.0 mg oral or intravenous
PTX-VF
15–30 IU/kg
Measure INR
Within 12 hours
Comments
Resume warfarin at reduced dose when INR reaches therapeutic range.

Management of patients on Warfarin therapy with high INR in Adults WITH Bleeding (1)

Warfarin
Stop
Vitamin K1
Give 5.0–10.0 mg intravenous
PTX-VF
Give 50 IU/kg
FFP
Give 150–300 mL
If PTX-VF not available administer FFP 15 mL/kg
Measure INR
In 20 mins
Comments
Resume warfarin when bleeding ceased and adjust dose to maintain INR within therapeutic range
Warfarin
Stop
Vitamin K1
Give 5.0–10.0 mg intravenous
PTX-VF
Give 30-50 IU/kg
FFP
If PTX-VF not available administer FFP 15 mL/kg
Measure INR
In 20 mins
Comments
Resume warfarin when bleeding ceased and adjust dose to maintain INR within therapeutic range
Warfrin
Stop
Measure INR
Within 24 hours
Comments
Resume warfarin at reduced dose when INR reaches therapeutic range.
Warfarin
Stop
Vitamin K1
Consider 1.0–2.0 mg oral or
0.5–1.0 mg intravenous
Measure INR
Within 24 hours
Comments
Resume warfarin at reduced dose when INR reaches therapeutic range.

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

Reference
  1. Tran HA, Chunilal SD, Harper PL, Tran H, Wood EM, Gallus AS. An update of consensus guidelines for warfarin reversal. MJA 2013;198(4):198–199.