Warfarin: Management of High INR

Key points

• Major bleeding: stop warfarin · IV vitamin K 5mg · prothrombin complex concentrate (FFP if unavailable — PCC preferred in intracranial haemorrhage as FFP takes time to defrost)
• INR > 8.0 with minor bleeding: stop warfarin · IV vitamin K 1-3mg · repeat if INR still too high after 24 h · restart when INR < 5.0
• INR > 8.0 with no bleeding: stop warfarin · vitamin K 1-5mg by mouth using the intravenous preparation orally · repeat after 24 h if needed · restart when INR < 5.0
• INR 5.0-8.0 with minor bleeding: stop warfarin · IV vitamin K 1-3mg · restart when INR < 5.0
• INR 5.0-8.0 with no bleeding: withhold 1 or 2 doses of warfarin and reduce the subsequent maintenance dose

Decision points in this pathway

• Major bleeding?
• INR > 8.0?

The full step-by-step algorithm, including what to do at each branch, opens in the app for approved members.