Warfarin reversal: Difference between revisions

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==Background==
==Background==
Vitamin K Guidelines for Warfarin (Coumadin) Reversal
#Goals:
##Identify and attenuate the cause of bleeding
##Lower the INR
#PO route for vit K is preferred due to superior efficacy compared to subq route


==Excessive Anticoagulation==
==Excessive Anticoagulation==
===INR < 5 No Bleeding===
===INR < 5 No Bleeding===
#↓ dose or omit dose
#Lower dose or omit one dose
#Resume at ↓ dose once INR therapeutic
#Resume at lower dose once INR therapeutic


===INR 5-9 No Bleeding===
===INR 5-9 No Bleeding===
# Omit 1-2 doses
#Hold next 1-2 doses
# Resume at ↓ dose once INR therapeutic
#Vit K 1-2.5mg po (only if pt is at high risk for bleeding)
# Vit K 1-2.5mg po if patient is at high risk for bleeding
##Age >75yr
##Concurrent antiplatelet drug use
##Polypharmacy
##Liver or renal disease
##Alcoholism
##Recent surgery
##Trauma
#Resume at lower dose once INR therapeutic


===INR ≥ 9 No Bleeding ===
===INR ≥ 9 No Bleeding ===
# Hold warfarin
#Hold warfarin
# Vit K 2.5-5mg po
#Vit K 2.5-5mg po
# INR will ↓ in 24-48h
#INR will decrease in 24-48h


==Specific Reversal Reasons==
==Specific Reversal Reasons==
===Undergoing Surgery===
===Undergoing Surgery===
# Omit dose
#Omit dose
# Give vit K 2-4mg po
#Give Vit K 2-4mg po
# ↓ in INR will occur in 24h
#Drop in INR will occur in 24h
# If INR still high, may give additional Vit K 1-2mg po
#If INR still high may give additional Vit K 1-2mg po


===Serious Bleeding===
===Life-Threatening Bleeding===
# Hold warfarin
#Hold warfarin
# Vit K 5-10mg subQ/IV
#Vitamin K
# FFP
##10mg slow IV push (may repeat in 12hr if INR still elevated)
# PCC or rFVIIa
##May induce unwanted thrombosis and/or overcorrection
# Vit K may be repeated q12h
#FFP
##Administer 10-15mL/kg (typically 3-4units)


==Treatment==
==Treatment==
#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
#Oral vitamin K is available in tablet and solution formulations


Revision as of 06:33, 21 October 2011

Background

  1. Goals:
    1. Identify and attenuate the cause of bleeding
    2. Lower the INR
  2. PO route for vit K is preferred due to superior efficacy compared to subq route

Excessive Anticoagulation

INR < 5 No Bleeding

  1. Lower dose or omit one dose
  2. Resume at lower dose once INR therapeutic

INR 5-9 No Bleeding

  1. Hold next 1-2 doses
  2. Vit K 1-2.5mg po (only if pt is at high risk for bleeding)
    1. Age >75yr
    2. Concurrent antiplatelet drug use
    3. Polypharmacy
    4. Liver or renal disease
    5. Alcoholism
    6. Recent surgery
    7. Trauma
  3. Resume at lower dose once INR therapeutic

INR ≥ 9 No Bleeding

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

Specific Reversal Reasons

Undergoing Surgery

  1. Omit dose
  2. Give Vit K 2-4mg po
  3. Drop in INR will occur in 24h
  4. If INR still high may give additional Vit K 1-2mg po

Life-Threatening Bleeding

  1. Hold warfarin
  2. Vitamin K
    1. 10mg slow IV push (may repeat in 12hr if INR still elevated)
    2. May induce unwanted thrombosis and/or overcorrection
  3. FFP
    1. Administer 10-15mL/kg (typically 3-4units)

Treatment

  1. Oral vitamin K is available in tablet and solution formulations

See Also

Warfarin (Coumadin)

Source

Ansell J, Hirsh J, Poller L et al. The Pharmacology and Management of the Vitamin K Antagonists. CHEST. 126(3S):204S-233S.

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