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Clinical Situation

Guidelines

INR >therapeutic range but <5.0, no clinically significant bleeding, rapid reversal not indicated for reasons of surgical intervention

• Lower the dose or omit the next dose; resume warfarin therapy at a lower dose when the INR approaches desired range

• If the INR is only minimally above therapeutic range, dose reduction may not be necessary

INR >5.0 but <9.0, no clinically significant bleeding

• Patients with no additional risk factors for bleeding; omit the next dose or two of warfarin, monitor INR more frequently, and resume warfarin therapy at a lower dose when the INR is in therapeutic range

• Patients at increased risk of bleeding: omit the next dose of warfarin, and give vitamin K (1.0 to 2.5 mg orally)

• Patients requiring more rapid reversal before urgent surgery or dental extraction: vitamin K (2–4 mg orally); if the INR remains high at 24 h, an additional dose of 1–2 mg