Management of Supratherapeutic INR

INR 2.0-3.0

- Therapeutic range

INR 3.0-5.0 without signs of bleeding:

- Lower warfarin dose if INR is minimally supratherapeutic

- Hold warfarin until INR is therapeutic, then resume at a lower dose

INR 5.0-9.0 without signs of bleeding:

- Hold warfarin and monitor INR frequently until INR is therapeutic, then resume at a lower dose

- Hold warfarin and give 1-2.5mg oral Vitamin K1

INR > 9.0 without signs of bleeding:

- Hold warfarin, give 5 to 10mg oral Vitamin K1, and monitor INR frequently until INR is therapeutic, then resume at a lower dose

Any INR with serious or life-threatening bleeding:

- Hold warfarin, give 10mg Vitamin K1 by slow IV infusion, supplement with prothrombin complex concentrate, FFP, or recombinant human factor VIIa, depending on clinical urgency

- Repeat as needed