Table 3.1-4. Management of patients with INR values above the therapeutic range

Clinical situation

Management

4.5 <INR <6.0 without bleeding

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

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 K1.c

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 fresh-frozen plasma.e

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 U corresponds to ~200 mL). Time to INR normalization is much longer than in the case of a prothrombin complex concentrate.

Based on Chest. 2012; 141 (2 Suppl): e1S–e801S.

INR, international normalized ratio; VKA, vitamin K antagonist (acenocoumarol, warfarin); PO, oral.