Warfarin reversal

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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

INR 4.5-10 No Bleeding[1]

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

INR >10 No Bleeding[2]

  1. Hold Warfarin
  2. Vitamin K 2.5 mg oral

Major Bleeding[3]

  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)
  4. If no PCC then give 2 unites Fresh Frozen Plasma
    1. No benefit to combining PCC and FFP

Consult cardiology in conjunction with hematology if patient has prosthetic valve

See Also

Source

  1. ↑ 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
  2. ↑ 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
  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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