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Management of elevated INR or bleeding in patients treated with vitamin K antagonists targeted at an INR range of 2.0 – 3.0* |
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| 3.0 < INR ≤ 3.5 (no bleeding) |
No dose reduction may be required Monitor INR again before lowering the dose |
| 3.5 < INR ≤ 5.0 (no bleeding) |
Omit dose Monitor daily and resume at lower dose when INR in therapeutic range |
| 5.0 < INR < 9.0 (no bleeding) |
Omit dose Give oral vitamin K1 (phytomenadione) 1 – 2.5 mg. Monitor daily and resume at lower dose when INR in therapeutic range |
| INR ≥ 9.0 (no bleeding) |
Hold vitamin K antagonist therapy Give oral vitamin K1 at higher dose (5 – 10 mg) with the expectation that the INR will be reduced substantially in 24 to 48 hours Monitor daily and give additional vitamin K1 if necessary Resume at lower dose when INR in therapeutic range Hospitalization may be considered if patient at higher risk of bleeding |
| Major bleeding at any elevation of INR |
Hospitalization Hold vitamin K antagonist therapy and give prothrombin concentrate complex supplemented with vitamin K1 (10 mg by slow intravenous infusion) Monitor from the fouth hour after prothrombin complex concentrate |
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* Modified after Ref. [2, 14] | |
Angelo et al. Thrombosis Journal 2007 5:1 doi:10.1186/1477-9560-5-1 |
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