Table 4.
Recommendations for Warfarin Anticoagulation Reversal
| 2008 ACCP Guidelines52 | 2012 ACCP Guidelines9, 45 | ||
|---|---|---|---|
| Clinical Presentation | Recommendation | Clinical Presentation | Recommendation |
| INR <5 (no severe bleeding) | No dose adjustment needed or Lower warfarin dose or Hold single warfarin dose | Mildly elevated INR (no severe bleeding) | No dose adjustment neededa or Lower warfarin dose or Hold single warfarin dose |
| INR ≥5 but <9 (no severe bleeding) | Hold one or two doses or Hold one dose + give vitK (1–2.5 mg orally) Give additional vitK if necessary (after 24 hours) | INR 4.5–10 (no severe bleeding) | Hold warfarin + give vitK if high risk of bleedb |
| INR ≥9 (no severe bleeding) | Hold warfarin + give vitK (2.5–5 mg orally) | INR > 10 (no severe bleeding) | Hold warfarin + give oral vitKc |
| Serious bleeding | Hold warfarin + give 10mg vitK by slow IV infusion + FFP, PCCs or rFVIIa depending on the urgency of the situation Repeat vitK every 12 hours if Needed | Severe/Life-threatening bleed | Hold warfarin + give 5–10 mg vitK IV slow infusion + give factor replacement (FFP, PCCs, rFVIIa)d |
| Life-threatening bleeding | Hold warfarin + give 10mg vitK by slow IV infusion + FFP, PCCs or rFVIIa Repeat reversal therapy if necessary (depending on the INR) | ||
vitK = vitamin K; INR = international normalized ratio; IV = intravenous; FFP = fresh frozen plasma; PCCs = prothrombin complex concentrates; rFVIIa = recombinant factor VIIa.
If single change in INR of ≤0.5.
Recommended vitamin K doses are not given in 2012 ACCP guidelines. Vitamin K is generally not recommended for non-bleeding patients with an INR between 4.5 and 10. Vitamin K should only be given to these patients if they have an increased risk of bleeding or require rapid INR reversal prior to surgery.
Recommended vitamin K doses are not given in 2012 ACCP guidelines. If the INR is >10 and the patient is not bleeding, clinical judgment should be used as to whether vitamin K should be given.
Four-factor PCCs are recommended above FFP and rFVIIa.
In the event of active major bleeding or urgent surgery requirement, the aim is to reach an INR level of <1.552. In addition to withholding warfarin and administering vitamin K intravenously, more rapid reversal strategies (via factor replacement) can be obtained by administering FFP, PCCs, or rFVIIa20.