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, PCC)	Hold	6-12 hours
Serious bleeding	Target or high INR	10 mg IV (<1 mg/min)	(FFP, PCC)	Hold	Following FFP

• * or Vitamin K 2.5 mg po. • FFP - Fresh Frozen Plasma. • PCC - Prothrombin Complex Concentration

Vitamin K

• The tablet size is 5 mg (in US). The practical smallest dose is 2.5 mg. (Dose of 1.0 mg can be obtained by withdrawing the right amount of Warfarin from a 10 mg vial of injectable vitamin K, dilutes with juice then given orally). Oral route is effective. Subcutaneous route may have unpredictable and delayed response. Intramuscular route may cause hematoma at the injection site.
• Intravenous route, utilizes when
  • Patient is unable to take oral medicine.
  • Patient who may have impair absorption.
  • Need rapid reversal of the INR.
  • Slow rate of infusion, at <1 mg/min, may help decrease the severity of anaphylactic reaction.
  • Large dose of intravenous administration may cause a period of warfarin resistance up to a week, when restarts it.