Table 2.

Recommendations for managing increased international normalized ratios or bleeding in patients rreceiving Vitamin K antagonists.

Condition	Description
INR above therapeutic range but <5.0; no significant bleeding	Lower dose or omit dose, monitor more frequently, and resume at lower dose when INR therapeutic; if only minimally above therapeutic range, no dose reduction may be required.
INR ≥5.0 but ≤10.0; no significant bleeding	Omit next one or two doses, monitor more frequently, and resume at lower dose when INR in therapeutic range. Alternatively, omit dose and give vitamin K1 (1–2.5 mg orally), particularly if at increased risk of bleeding. If more rapid reversal is required because the patient requires urgent surgery, vitamin K1 (2–4 mg orally) can be given with the expectation that the INR will decrease in 24 hours. If the INR is still high, additional vitamin K1 (1–2 mg orally) can be given.
INR >10.0; no significant bleeding	Hold warfarin therapy and give higher dose of vitamin K1 (5–10 mg orally) with the expectation that the INR will be reduced substantially in 24–48 hours. Monitor more frequently, and use additional vitamin K1 if necessary. Resume therapy at lower dose when INR therapeutic.
Serious or life-threatening bleeding at any elevation of INR	Hold warfarin therapy and give vitamin K1 (10 mg by slow IV infusion), supplemented with 4-factor prothrombin complex concentrate or fresh frozen plasma. Vitamin K1 can be repeated every 12 hours.

^*Adapted from Holbrook A, et al. 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;141:e152S–184S.