Warfarin reversal

Background

Vitamin K Guidelines for Warfarin (Coumadin) Reversal

Excessive Anticoagulation

INR < 5 No Bleeding

1. ↓ dose or omit dose
2. Resume at ↓ dose once INR therapeutic

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

INR ≥ 9 No Bleeding

1. Hold warfarin
2. Vit K 2.5-5mg po
3. INR will ↓ in 24-48h

Specific Reversal Reasons

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 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

Treatment

1. 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.