Warfarin reversal: Difference between revisions
 
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==Background==
==Background==
#Vitamin K
*For supratheraputic INR on warfarin
##PO route for vit K is preferred to subq route due to superior efficacy
*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>
##IV route carries rare but serious risk of anaphylaxis
###Only give for pts with:
####Life-threatening bleeding
####INR >20
####Symptomatic pts poisoned by suicidal ingestion of warfarin or rodenticide
==Excessive Anticoagulation==
===INR < 5 No Bleeding===
#Lower dose or omit one dose
#Resume at lower dose once INR therapeutic


===INR 5-9 No Bleeding===
===Target INR===
#Hold next 1-2 doses
*Vascular thrombosis (DVT, PE): 2.0-3.0
#Vit K 1-2.5mg po (only if pt is at high risk for bleeding)
*Most mechanical heart valves: 3.0-4.5
##Age >75yr
**Bileaflet mechanical aortic heart valves: 2.5-3.5
##Concurrent antiplatelet drug use
##Polypharmacy
##Liver or renal disease
##Alcoholism
##Recent surgery
##Trauma
#Resume at lower dose once INR therapeutic


===INR > 9 No Bleeding ===
===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>===
#Hold warfarin
{| class="wikitable"
#Vit K 2.5-5mg po
| align="center" style="background:#f0f0f0;"|'''Risk Factor'''
#INR will decrease in 24-48h
| 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
|}


===Life-Threatening Bleeding===
[[File:Supratherapeutic_inr.png|thumb|Algorithm for the management of supratherapeutic INR]]
#Hold warfarin
 
#Give Prothrombin complex concentrate or factor VII
==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>==
#Vitamin K
 
##Give if PCC nor factor VII are available
===INR 4.5-10 No Bleeding===
##10mg slow IV push (may repeat in 12hr if INR still elevated)
#Hold Warfarin
##May induce unwanted thrombosis and/or overcorrection
#Resume Warfarin at lower dose once INR therapeutic
#FFP
#Not recommended to give Vitamin K
##Administer 10-15mL/kg (typically 3-4units)
 
===INR >10 No Bleeding===
#Hold Warfarin
#[[Vitamin K]] 2.5mg oral
 
===Major Bleeding===
{{Warfarin Reversal}}
 
'''''Consult cardiology in conjunction with hematology if patient has prosthetic valve'''''


==See Also==
==See Also==
*[[Coagulopathy (Main)]]
*[[Warfarin (Coumadin)]]
*[[Warfarin (Coumadin)]]
*[[Dabigatran Reversal]]
*[[Anticoagulant reversal for life-threatening bleeds]]
 
==Video==
{{#widget:YouTube|id=Qmgq0BvvZ7U}}


==Source==
==References==
Tintinalli
<references/>


[[Category:Drugs]]
[[Category:Pharmacology]]
[[Category:Heme/Onc]]
[[Category:Heme/Onc]]
[[Category:Tox]]
[[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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