Guidelines for the Management of Supratherapeutic INR ...
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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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