Warfarin reversal

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

Reversal for patients 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 ≥ 9 No Bleeding

1. Hold warfarin

2. Vit K 2.5-5mg po

3. INR will ↓ in 24-48h

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

• • • 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.