Anticoagulation Management Service For Health Professionals
Guidelines for Management of Patients with INR 5.0 - 9.0
University of Michigan Anticoagulation Service
- Contact patient and attempt to identify reasons for prolonged INR (e.g. drug interaction, change in diet, acute illness).
- Exclude significant active bleeding by review of systems. If present, refer for immediate medical evaluation.
- Counsel the patient to avoid excessive physical activity while his/her INR is prolonged, and to report immediately symptoms/signs of bleeding.
- Hold warfarin for 1-2 doses (also see No. 7).
- Strongly consider vitamin K 1.25-2.5 mg po if patient is at increased risk of bleeding. At present, vitamin K pills are available only as 5.0 mgs. Therefore, prescribe 1/4 or 1/2 of a 5 mg tablet-i.e. sectioning of the pill should be performed by a pharmacist.
- If INR is > or = to 6.0, notify patient's primary physician or Anticoagulation Clinic physician of critical value and treatment plan.
- Arrange follow-up INR monitoring in 1-2 days, then at appropriate intervals, depending on the degree of INR prolongation and whether or not vitamin K was administered. If vitamin K 1.25-2.5 mg po was given, check INR daily for several days, since INR may become subtherapeutic after vitamin K administration.
- Resume warfarin once INR is therpeutic.
- Consider reducing the patient's weekly warfarin dose by 10-15%, unless a cause for the prolonged INR was established and corrected.
- May want to consider restarting Coumadin before INR reaches therapeutic range in patient who received vitamin K therapy.
Revised 10/08/08
