Anticoagulation Service For Health Professionals

Synopsis of Guidelines for Managing Prolonged INR's - Part I

Notes:
1. An approach to the management of patients who are excessively over anticoagulated and either have minor bleeding or no obvious bleeding is outlined.
2. In all cases, warfarin treatment should be interrupted the INR checked and warfarin restarted at a lower dose when the INR returns to the therapeutic range.
3. If the INR is above 5 but below 9, oral Vitamin K, should be considered if the patient is at excessive risk of bleeding.

Managing High INR Values
Patients with No or Minor Bleeding

Clinical Situation Guidelines
INR > therapeutic range but <5.0, no clinically significant bleeding, rapid reversal not indicated for reasons of surgical intervention Lower the dose or omit the next dose; resume warfarin therapy at a lower dose when the INR approaches desired range

If the INR is only minimally above therapeutic range, dose reduction may not be necessary

INR >5.0 but <9.0, no clnically significant bleeding Patients with no additional risk factors for bleeding; omit the next dose or two of warfarin, monitor INR more frequently, and resume warfarin therapy at a lower dose when the INR is in therapeutic range

Patients at increased risk of bleeding: omit the next dose of warfarin, and give vitamin K1 (1.0 to 2.5 mg orally)

Patients requiring more rapid reversal before urgent surgery or dental extraction: vitamin K1 (2-4 mg orally); if the INR remains high at 24 h, an additional dose of 1-2 mg

7 th ACCP Conference on Antithrombotic and Thrombolytic Therapy: Evidence-Based Guidelines, 2004