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04/30/2012

Managing Elevated INRs in Patients Taking Warfarin

For most patients, warfarin would be considered a non-palliative medication that we would recommend discontinuing while on hospice. Warfarin can be especially difficult to manage at the end of life due to rapidly changing physiologic function and oral intake combined with many potential drug-drug interactions. Patients who continue taking warfarin while on hospice often experience fluctuations in their INR, sometimes resulting in a high INR that the hospice must manage in order to prevent a life-threatening bleed.

There has been a slight change in anticoagulation guidelines (see reference below) surrounding when to use vitamin K. Previous guidelines suggested holding warfarin and giving vitamin K for INRs between 5 and 9. Now, the recommendation is to NOT give vitamin K, if there is no bleeding, unless the INR is greater than 10. The evidence seems to be that giving vitamin K for INRs between 5 and 9 doesn’t prevent bleeding better than just holding warfarin, and it may lower the INR too much or for too long.

Use the following chart to help you manage high INRs in your warfarin patients.

Elevated INR;

No Significant Bleeding

INR above therapeutic range but < 4.5
  • Reduce or skip warfarin dose.
  • Monitor INR and resume warfarin, potentially at lower dose, when INR is back in therapeutic range.

INR 4.5 – 10
  • Hold 1-2 doses of warfarin.
  • Vitamin K not routinely recommended if there is no evidence of bleeding.
  • If bleeding risk is high, consider vitamin K 1-2.5 mg PO x 1.
  • Monitor INR and resume warfarin at lower dose when INR is back in therapeutic range.

INR > 10
  • Hold warfarin.
  • Give vitamin K 2.5-5 mg PO x 1.
  • Monitor INR and resume warfarin at lower dose when INR is back in therapeutic range.

Significant Bleeding

Any INR
  • Hold warfarin.
  • Give vitamin K 5-10 mg by slow IV infusion (dilute in at least 50 mL of IV fluid and administer over at least 20 minutes). Do not give subcutaneously – absorption is unreliable.
  • Give either prothrombin complex concentrate (PCC) or fresh frozen plasma (FFP).
  • Monitor INR and resume warfarin at lower dose when INR is back in therapeutic range.

When an elevated INR needs to be rapidly reversed, such as before surgery, use vitamin K 1-5 mg PO x 1 and repeat in 24 hours if needed.

 

Reference:

For updated anticoagulation guidelines, see “Antithrombotic Therapy and Prevention of Thrombosis, 9th edition: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines” in the February 2012 issue of Chest.

 

Posted on April 30, 2012

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Tags: warfarin, Coumadin, INR, vitamin K


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