Warfarin reversal: Difference between revisions
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=Excessive Anticoagulation=
=Excessive Anticoagulation=
==INR < 5 No Bleeding==
==INR ≤ 10 No Bleeding==
#Give lower dose of warfarin or omit one dose of warfarin
#Hold Coumadin
#Resume warfarin at lower dose once INR therapeutic
#Resume Coumadin at lower dose once INR therapeutic


==INR 5-9 No Bleeding==
==INR > 10 No Bleeding==
#Omit next 1-2 doses of warfarin
#Hold Coumadin
#Vitamin K 1-2.5 mg oral: if patient at ''high risk'' for bleeding
#Vitamin K 2.5 mg oral
##''Age >75 years''
##''Concurrent antiplatelet drug use''
##''Polypharmacy''
##''Liver or kidney disease''
##''Alcoholism''
##''Recent surgery''
##''Trauma''
#Resume warfarin at lower dose once INR therapeutic


==INR > 9 No Bleeding ==
 
==Major Bleeding ==
#Stop warfarin
#Stop warfarin
#Give Vitamin K 2.5-5 mg po: INR will decrease over 24-48 hours
#Give Vitamin K 5-10mg IV INR will decrease over 24-48 hours (small risk of anaphylaxis with IV Vit K)
#Give 4 Factor Prothrombin Complex Concentrate (PCC)
#If no PCC then give 2 unites Fresh Frozen Plasma
:(no benefit to combining PCC and FFP


==Life-Threatening Bleed==
#Stop warfarin
#Give 4-factor Prothrombin Complex Concentrate (PCC) or 3-factor PCC + recombinant factor VIIa
#Give Vitamin K if PCC or factor VII not available
##10mg slow IV push: may repeat in 12 hours if INR still elevated
##May induce unwanted thrombosis and/or overcorrection
#Give IV Fresh Frozen Plasma (FFP) 10-15 mL/kg: for 70 kg patient, 3 units = 750 ml


==See Also==
==See Also==

Revision as of 03:45, 5 February 2014

Background

  1. Vitamin K
    1. Oral route is preferred over subcutaneous route: superior efficacy
    2. Intravenous route carries rare but serious risk of anaphylaxis
    3. Only give for patient with:
      1. Life-threatening bleeding
      2. INR >20
      3. Symptomatic patient poisoned by suicidal ingestion of warfarin or rodenticide

Excessive Anticoagulation

INR ≤ 10 No Bleeding

  1. Hold Coumadin
  2. Resume Coumadin at lower dose once INR therapeutic

INR > 10 No Bleeding

  1. Hold Coumadin
  2. Vitamin K 2.5 mg 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 Vit K)
  3. Give 4 Factor Prothrombin Complex Concentrate (PCC)
  4. If no PCC then give 2 unites Fresh Frozen Plasma
(no benefit to combining PCC and FFP


See Also

Source

Tintinalli

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