Guidelines for the Management of Supratherapeutic INR - American College of Chest Physicians
INR above therapeutic range but < 5.0
• Lower dose or omit dose
• Monitor more frequently and resume at lower dose when INR falls within therapeutic range (if INR only slightly above range, may not be necessary to decrease dose)
INR > 5.0 but INR < 9.0
• Hold next 1—2 doses
• Monitor more frequently and resume therapy at lower dose when INR falls within therapeutic range
• Patients at high risk for bleeding: Hold warfarin and consider giving vitamin K1
1-2.5 mg orally; check INR in 24-48 h to ensure response to therapy
INR > 9.0
• Hold warfarin
• Vitamin K1 2.5-5 mg orally
• Monitor frequently and resume therapy at lower dose when INR within therapeutic range
Life Threatening Bleed
• Hold warfarin and give 10 mg vitamin K by slow intravenous infusion supplemented by FFP, PCC, or recombinant factor VIIa (PCC preferred)
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