Warfarin reversal: Difference between revisions

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Vitamin K Guidelines for Warfarin (Coumadin) Reversal== ==
==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>


===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


==Excessive Anticoagulation==
===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"
| align="center" style="background:#f0f0f0;"|'''Risk Factor'''
| align="center" style="background:#f0f0f0;"|'''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
|}


[[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>==


===INR < 5 No Bleeding===
===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


1.    ↓ dose or omit dose
===Major Bleeding===
{{Warfarin Reversal}}


2.    Resume at ↓ dose once INR therapeutic
'''''Consult cardiology in conjunction with hematology if patient has prosthetic valve'''''
 
 
===INR 5-9 No Bleeding===
 
 
1.    Omit 1-2 doses
 
2.    Resume at ↓ dose once INR therapeutic
 
3.    Vit K 1-2.5mg po if patient is at high risk for bleeding
 
 
Reversal for patients undergoing surgery:1.    Omit dose
 
2.    Give vit K 2-4mg po
 
3.    ↓ in INR will occur in 24h
 
4.    If INR still high, may give additional Vit K 1-2mg po
 
 
===INR ≥ 9 No Bleeding ===
 
 
1. Hold warfarin
 
2. Vit K 2.5-5mg po
 
3. INR will ↓ in 24-48h
 
 
===INR therapeutic or elevated with Serious Bleeding===
 
 
1.    Hold warfarin
 
2.    Vit K 5-10mg subQ/IV
 
3.    FFP
 
4.    PCC or rFVIIa
 
5.    Vit K may be repeated q12h
 
 
***Oral route for vitamin K is preferred due to superior efficacy compared to subcutaneous route. Oral vitamin K is available in tablet and solution formulations.
 
 
 
 
Source
 
Ansell J, Hirsh J, Poller L et al. The Pharmacology and Management of the Vitamin K Antagonists. CHEST. 126(3S):204S-233S.


==See Also==
*[[Coagulopathy (Main)]]
*[[Warfarin (Coumadin)]]
*[[Anticoagulant reversal for life-threatening bleeds]]


==Video==
{{#widget:YouTube|id=Qmgq0BvvZ7U}}


==References==
<references/>


[[Category:Pharmacology]]
[[Category:Heme/Onc]]
[[Category:Heme/Onc]]
[[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
Algorithm for the management of supratherapeutic INR

Treatment based on INR[3]

INR 4.5-10 No Bleeding

  1. Hold Warfarin
  2. Resume Warfarin at lower dose once INR therapeutic
  3. Not recommended to give Vitamin K

INR >10 No Bleeding

  1. Hold Warfarin
  2. Vitamin K 2.5mg oral

Major Bleeding

  1. Stop warfarin
  2. Give Vitamin K 5-10mg IV INR will decrease over 24-48 hours (small risk of anaphylaxis with IV Vitamin K)
  3. Give 4 Factor prothrombin complex concentrate (PCC)

Consult cardiology in conjunction with hematology if patient has prosthetic valve

See Also

Video

{{#widget:YouTube|id=Qmgq0BvvZ7U}}

References

  1. ↑ Hylek EM, Singer DE. Risk factors for intracranial hemorrhage in outpatients taking warfarin. Ann Intern Med.1994;120:897-902.
  2. ↑ Hylek, E et al. Acetaminophen and Other Risk Factors for Excessive Warfarin Anticoagulation. JAMA. 1998;279(9):657-662 PDF
  3. ↑ 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
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