Warfarin reversal: Difference between revisions
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==Background== | ==Background== | ||
*For supratheraputic INR on warfarin | |||
*Intracranial hemorrhage is significantly increased with an INR > 4.0<ref>Hylek EM, Singer DE. Risk factors for intracranial hemorrhage in outpatients taking warfarin. Ann Intern Med.1994;120:897-902.</ref> | *Intracranial hemorrhage is significantly increased with an INR > 4.0<ref>Hylek EM, Singer DE. Risk factors for intracranial hemorrhage in outpatients taking warfarin. Ann Intern Med.1994;120:897-902.</ref> | ||
===Target INR=== | ===Target INR=== | ||
*Vascular thrombosis (DVT, PE): 2.0-3.0 | |||
*Most mechanical heart valves: 3.0-4.5 | *Most mechanical heart valves: 3.0-4.5 | ||
**Bileaflet mechanical aortic heart valves: 2.5-3.5 | **Bileaflet mechanical aortic heart valves: 2.5-3.5 | ||
===Risk | ===Risk Factors for INR > 6.0<ref>Hylek, E et al. Acetaminophen and Other Risk Factors for Excessive Warfarin Anticoagulation. JAMA. 1998;279(9):657-662 [http://jama.jamanetwork.com/data/Journals/JAMA/4550/JOC71452.pdf PDF]</ref>=== | ||
{| class="wikitable" | {| class="wikitable" | ||
| align="center" style="background:#f0f0f0;"|'''Risk Factor''' | | align="center" style="background:#f0f0f0;"|'''Risk Factor''' | ||
| Line 14: | Line 15: | ||
| Malignancy||16.4 | | Malignancy||16.4 | ||
|- | |- | ||
| Tylenol Intake > | | Tylenol Intake > 9100 mg/week||10 | ||
|- | |- | ||
| New Medication||8.5 | | New Medication||8.5 | ||
|- | |- | ||
| | | Increased Warfarin Intake||8.1 | ||
|- | |- | ||
| Tylenol Intake | | Tylenol Intake 4550 mg - 9099 mg/week||6.9 | ||
|- | |- | ||
| Decrease Vitamin K intake||3.6 | | Decrease Vitamin K intake||3.6 | ||
| Line 26: | Line 27: | ||
| Acute Diarrheal Illness||3.5 | | Acute Diarrheal Illness||3.5 | ||
|} | |} | ||
[[File:Supratherapeutic_inr.png|thumb|Algorithm for the management of supratherapeutic INR]] | |||
==Treatment based on INR<ref>Holbrook A, et al; American College of Chest Physicians. Evidence-based management of anticoagulant therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012 Feb;141 [http://www.siapav.it/pdf/Chest%202012.pdf PDF]</ref>== | ==Treatment based on INR<ref>Holbrook A, et al; American College of Chest Physicians. Evidence-based management of anticoagulant therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012 Feb;141 [http://www.siapav.it/pdf/Chest%202012.pdf PDF]</ref>== | ||
| Line 36: | Line 39: | ||
===INR >10 No Bleeding=== | ===INR >10 No Bleeding=== | ||
#Hold Warfarin | #Hold Warfarin | ||
#[[Vitamin K]] 2. | #[[Vitamin K]] 2.5mg oral | ||
===Major Bleeding=== | ===Major Bleeding=== | ||
| Line 46: | Line 49: | ||
*[[Coagulopathy (Main)]] | *[[Coagulopathy (Main)]] | ||
*[[Warfarin (Coumadin)]] | *[[Warfarin (Coumadin)]] | ||
*[[ | *[[Anticoagulant reversal for life-threatening bleeds]] | ||
==Video== | |||
{{#widget:YouTube|id=Qmgq0BvvZ7U}} | |||
== | ==References== | ||
<references/> | <references/> | ||
[[Category: | [[Category:Pharmacology]] | ||
[[Category:Heme/Onc]] | [[Category:Heme/Onc]] | ||
[[Category: | [[Category:Toxicology]] | ||
Latest revision as of 20:46, 22 December 2020
Background
- For supratheraputic INR on warfarin
- Intracranial hemorrhage is significantly increased with an INR > 4.0[1]
Target INR
- Vascular thrombosis (DVT, PE): 2.0-3.0
- Most mechanical heart valves: 3.0-4.5
- Bileaflet mechanical aortic heart valves: 2.5-3.5
Risk Factors for INR > 6.0[2]
| Risk Factor | Odds Ratio |
| Malignancy | 16.4 |
| Tylenol Intake > 9100 mg/week | 10 |
| New Medication | 8.5 |
| Increased Warfarin Intake | 8.1 |
| Tylenol Intake 4550 mg - 9099 mg/week | 6.9 |
| Decrease Vitamin K intake | 3.6 |
| Acute Diarrheal Illness | 3.5 |
Treatment based on INR[3]
INR 4.5-10 No Bleeding
- Hold Warfarin
- Resume Warfarin at lower dose once INR therapeutic
- Not recommended to give Vitamin K
INR >10 No Bleeding
- Hold Warfarin
- Vitamin K 2.5mg oral
Major Bleeding
- Stop warfarin
- Give Vitamin K 5-10mg IV INR will decrease over 24-48 hours (small risk of anaphylaxis with IV Vitamin K)
- Give 4 Factor prothrombin complex concentrate (PCC)
- If no PCC, then give 15 ml/kg fresh frozen plasma (no benefit to combining PCC and FFP)
Consult cardiology in conjunction with hematology if patient has prosthetic valve
See Also
Video
{{#widget:YouTube|id=Qmgq0BvvZ7U}}
References
- ↑ Hylek EM, Singer DE. Risk factors for intracranial hemorrhage in outpatients taking warfarin. Ann Intern Med.1994;120:897-902.
- ↑ Hylek, E et al. Acetaminophen and Other Risk Factors for Excessive Warfarin Anticoagulation. JAMA. 1998;279(9):657-662 PDF
- ↑ Holbrook A, et al; American College of Chest Physicians. Evidence-based management of anticoagulant therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012 Feb;141 PDF