4.5 <INR <6.0 without bleeding

1) Discontinue VKA until the INR is 2.0-3.0a

2) Do not administer vitamin K1 routinely

INR 6.0-10.0 without bleeding

1) Discontinue VKA until the INR is 2.0-3.0

2) You may administer 2.5-5 mg of POb vitamin K1c

INR >10.0 without bleeding

1) Discontinue VKA

2) Administer 2.5-5 mg of POb vitamin K1

Severe bleeding associated with VKA

1) Discontinue VKA

2) Immediately neutralize the anticoagulant effect by administering a 4-factor prothrombin complex concentrated rather than frozen plasmae

3) In the case of refractory life-threatening bleeding, consider a recombinant factor VIIa concentrate

4) Additionally administer 2.5-5 mg of vitamin K1 in a slow IV infusion

a Discontinuation of the treatment for 1-2 days is usually sufficient.

b Use of high doses of vitamin K1 may cause resistance to VKAs lasting ~7 days.

c Some experts (including the American College of Chest Physicians) do not recommend the routine administration of vitamin K1.

d In patients with an INR >6.0, administration of a prothrombin complex concentrate in a dose 50 IU/kg usually results in INR normalization within 10-15 min; such treatment is necessary particularly in patients with intracranial or other life-threatening bleeding.

e The optimum dose of fresh frozen plasma has not been established; the usual dose is 10-15 mL/kg (1 IU corresponds to ~200 mL). Time to INR normalization is much longer than in the case of a prothrombin complex concentrate.