Table 1 Management of elevated INR or bleeding in patients treated with vitamin K antagonists targeted at an INR range of 2.0 – 3.0*

3.0 < INR ≤ 3.5 (no bleeding)

No dose reduction may be required

Monitor INR again before lowering the dose

3.5 < INR ≤ 5.0 (no bleeding)

Omit dose

Monitor daily and resume at lower dose when INR in therapeutic range

5.0 < INR < 9.0 (no bleeding)

Omit dose

Give oral vitamin K₁ (phytomenadione) 1 – 2.5 mg.

Monitor daily and resume at lower dose when INR in therapeutic range

INR ≥ 9.0 (no bleeding)

Hold vitamin K antagonist therapy

Give oral vitamin K₁ at higher dose (5 – 10 mg) with the expectation that the INR will be reduced substantially in 24 to 48 hours

Monitor daily and give additional vitamin K₁ if necessary

Resume at lower dose when INR in therapeutic range

Hospitalization may be considered if patient at higher risk of bleeding

Major bleeding at any elevation of INR

Hospitalization

Hold vitamin K antagonist therapy and give prothrombin concentrate complex supplemented with vitamin K₁ (10 mg by slow intravenous infusion)

Monitor from the fouth hour after prothrombin complex concentrate