Warfarin reversal

Background

• For supratheraputic INR on warfarin
• Intracranial hemorrhage is significantly increased with an INR > 4.0

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

Risks Factors for INR > 6.0

Risk Factor	Odds Ratio
Malignancy	16.4
Tylenol Intake > 9100mg/week	10
New Medication	8.5
Incrased Warfarin Intake	8.1
Tylenol Intake 4550mg-9099mg /week	6.9
Decrease Vitamin K intake	3.6
Acute Diarrheal Illness	3.5

Treatment based on INR

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 2.5 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 Vitamin K)
3. Give 4 Factor prothrombin complex concentrate (PCC)
   • If no PCC, then give 15 ml/kg fresh frozen plasma (no benefit to combining PCC and FFP)

Consult cardiology in conjunction with hematology if patient has prosthetic valve

See Also

• Coagulopathy (Main)
• Warfarin (Coumadin)
• Dabigatran Reversal