INR

RECOMMENDATION

Less than 5 and no bleeding

No vitamin K. Lower or omit warfarin dose; resume at lower dose when INR in therapeutic range.

5 or greater but less than 9 and no bleeding

Hold warfarin x 1-2 doses; resume at lower dose when in INR therapeutic range. May give vitamin K 1-2.5 mg PO* or slow IV. Review INR within 24 hours. 

 If more rapid reversal required, give vitamin K £ 5mg PO or slow IV. May repeat vitamin K 1-2mg if necessary at 24 hours.

9 or greater and no bleeding

Hold warfarin. Give vitamin K 2.5-5 mg PO or slow IV. Review INR in 12 hours.

Serious bleed

Hold warfarin. Give vitamin K 10mg slow IV supplemented with fresh frozen plasma.  Review INR in 12 hours and repeat vitamin K if necessary.