Table 8. Managing high INR or bleeding.
BLEEDING BLEEDING INR VITAMIN K FFP WARFARIN NEXT INR No bleeding <5 None None Hold 1-2 days. -- Adjust dose? 1-2 days No bleeding 5-9 None (No bleeding risk) * None Hold 1-2 days. --Adjust dose 1 day Minor bleeding <10 2.5 mg po None
Hold ----- Adjust dose
1 day No bleeding or minor bleeding 10-20 2.5-5.0 mg po None Hold ----- Adjust dose 12-24 hours Bleeding tendency or bleeding >20 5-10 mg IV (<1 mg/min) (FFP, PCC) Hold 6-12 hours Serious bleeding Target or high INR 10 mg IV (<1 mg/min) (FFP, PCC) Hold Following FFP
* or Vitamin K 2.5 mg po. FFP - Fresh Frozen Plasma. PCC - Prothrombin Complex Concentration
- The tablet size is 5 mg (in US). The practical smallest dose is 2.5 mg. (Dose of 1.0 mg can be obtained by withdrawing the right amount of Warfarin from a 10 mg vial of injectable vitamin K, dilutes with juice then given orally). Oral route is effective. Subcutaneous route may have unpredictable and delayed response. Intramuscular route may cause hematoma at the injection site.
- Intravenous route, utilizes when
- Patient is unable to take oral medicine.
- Patient who may have impair absorption.
- Need rapid reversal of the INR.
- Slow rate of infusion, at <1 mg/min, may help decrease the severity of anaphylactic reaction.
- Large dose of intravenous administration may cause a period of warfarin resistance up to a week, when restarts it.