Table 8. Managing high INR or bleeding.

BLEEDING BLEEDING	INR	VITAMIN K	FFP	WARFARIN	NEXT INR
No bleeding	<5	None	None	Hold 1-2 days. -- Adjust dose?	1-2 days
No bleeding	5-9	None (No bleeding risk) *	None	Hold 1-2 days. --Adjust dose	1 day
Minor bleeding	<10	2.5 mg po	None	Hold ----- Adjust dose	1 day
No bleeding or minor bleeding	10-20	2.5-5.0 mg po	None	Hold ----- Adjust dose	12-24 hours
Bleeding tendency or bleeding	>20	5-10 mg IV (<1 mg/min)	FFP?	Hold	6-12 hours
Serious bleeding	Target or high INR	10 mg IV (<1 mg/min)	FFP	Hold	Following FFP

• * or Vitamin K 2.5 mg po.
• FFP - Fresh Frozen Plasma.

Vitamin K

• The tablet size is 5 mg. The practical smallest dose is 2.5 mg.
• Oral route is effective.
• Subcutaneous route may have unpredictable and delayed response.
• Intramuscular route may cause hematoma at the injection site.
• Intravenous route, utilize when
  • Patient is unable to take oral medicine.
  • Patient who may have impair absorption.
  • Need rapid reversal of the INR. The dose is 5 - 10 mg (dose for patient who does not need rapid reversal of INR is 1-3 mg). Slow rate of infusion, at <1 mg/min, should help decrease the incident of anaphylactic reaction.
  • Large dose of intravenous administration may cause a period of warfarin resistance up to a week, when restart it.