Supratheraputic INR

Management of Elevated INR in Patients Receiving Vitamin K Antagonists2

INR Bleeding Present Rapid Reduction Required Management*
<5 No No Lower dose or omit dose;
Resume at lower dose when INR is herapeutic
5-9 No No Omit one or two doses,
Resume at lower dose.
No Yes -
High risk
May give vitamin K1 1-2.5 mg orally if at increased risk for bleeding.
No Yes -
2-4 mg oral vitamin K for reduction of INR in 24 hours;
If INR still high, can repeat with 1-2 mg orally.
≥9 No No Hold dose.
Give vitamin K 5 - 10 mg orally to reduce INR in 24 to 48 hours; may use additional vitamin K as necessary.
Resume at lower dose when therapeutic.

Serious Bleeding 
Yes Hold dose.
Give Vitamin K 10 mg by slow IV infusion, supplemented with FFP, prothrombin complex, or recombinant factor VIIa;
Vitamin K1 may be repeated every 12 hours.
Any Yes

Life Threatening
Yes Hold dose.
Give prothrombin complex supplemented with Vitamin K1 10 mg by slow IV infusion;
Repeat if necessary depending on INR.