Guidelines for the management of an elevated INR in adults

Management of patients on Warfarin therapy with high INR in Adults WITHOUT Bleeding (1)
INR Bleeding risk Warfarin Vitamin K1 FFP PTX-VF Measure INR Comments
>therapeutic range but <4.5  

Reduce or omit the next dose*

        Resume warfarin at reduced dose when INR reaches therapeutic range.

 

4.5–10.0
 

Low

Stop

        Within 24 hours 
High

Give 1.0−2.0 mg oral or 0.5–1.0 mg intravenous

>10.0  Low Stop  Give 3.0−5.0 mg oral or intravenous     Within 12 hours
High Give 3.0−5.0 mg oral or intravenous   15–30 IU/kg

Management of patients on Warfarin Therapy WITH Bleeding (1)

 INR Bleeding risk  Warfarin Vitamin K1 FFP PTX-VF Check INR Comments
≥1.5 with life threatening (critical organ) bleeding   Stop   Give 5.0–10.0 mg intravenous 

Give 150–300 mL

 

If PTX-VF not available administer FFP 15 mL/kg

Give 50 IU/kg In 20 mins     Resume warfarin when bleeding ceased and adjust dose to maintain INR within therapeutic range
≥2.0 with clinically significant bleeding (not life threatening)   Stop Give 5.0–10.0 mg intravenous  If PTX-VF not available administer FFP 15 mL/kg Give 35–50 IU/kg In 20 mins
Any INR with minor bleeding or INR >4.5 with minor bleeding Low Stop       In 24 hours Resume warfarin at reduced dose when INR reaches therapeutic range
High Consider 1.0–2.0 mg oral or 0.5–1.0 mg intravenous    

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.
  2. 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.