INR

Recommendation

< 5 and no bleeding

No vitamin K. Hold warfarin until INR in therapeutic range.

5-9 and no bleeding

Hold warfarin until INR in 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 and repeat 1-2mg if necessary at 24 hours.

> 9 and no bleeding

Vitamin K 5-10 mg PO or slow IV. Review INR in 12 hours.

Serious bleed

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