[Updated on 4th August 2024]
This guideline summarizes the management of bleeding or supra therapeutic international normalized ratio (INR), in a patient who is taking warfarin.
The management depends on whether the patient is having major bleeding, non-major bleeding or no bleeding.
Major bleeding
Major bleeding, in terms of anticoagulation reversal, can be defined as limb or life-threatening bleeding that requires complete reversal within 6–8 hours.
- Withold warfaring
- Emergency anticoagulation reversal in patients with major bleeding should be with 25–50 units/kg four-factor prothrombin complex concentrate and 5 mg intravenous vitamin K (1B).
- Recombinant factor VIIa is not recommended for emergency anticoagulation reversal (1B).
- Fresh frozen plasma produces suboptimal anticoagulation reversal and should only be used if prothrombin complex concentrate is not available (1C).
Non-major bleeding
Any bleeding which is not categorised under major bleeding should be managed as non major bleeding.
- Withold warfarin
- Anticoagulation reversal for non-major bleeding should be with 1–3 mg intravenous vitamin K (1B).
- If INR > 8:
- Repeat INR in 24 hours, if still INR > 8, repeat dose of vitamin K.
- Restart warfaring in a lower dose when INR < 5.
- If INR 5 – 8:
- Restart warfaring in a lower dose when INR < 5.
No bleeding
- If INR > 8:
- Give 1–5 mg of oral vitamin K (1B).
- Repeat INR in 24 hours, if still INR > 8, repeat the dose of oral vitamin K.
- Restart warfarin in a lower dose when INR < 5.
- If INR 5 – 8:
- Withold 1–2 doses of warfarin and reduce the maintenance dose (1B).
- The cause of the elevated INR should be investigated (1C).
References
- Keeling, D., Baglin, T., Tait, C., Watson, H., Perry, D., Baglin, C., Kitchen, S., Makris, M. and (2011), Guidelines on oral anticoagulation with warfarin – fourth edition. British Journal of Haematology, 154: 311-324. https://doi.org/10.1111/j.1365-2141.2011.08753.x