What is the management for a patient with an elevated International Normalized Ratio (INR)?

Management of Elevated INR

For patients with elevated INR, management should be based on the INR level, presence of bleeding, and underlying clinical conditions, with prothrombin complex concentrate (PCC) plus vitamin K being the preferred treatment for warfarin-associated elevated INR with active bleeding. 1

Assessment of Elevated INR

• Evaluate for clinical signs of bleeding (intracranial, gastrointestinal, genitourinary, retroperitoneal)
• Determine INR level and time since last warfarin dose
• Identify contributing factors:
  • Drug interactions
  • Dietary changes (reduced vitamin K intake)
  • Liver disease
  • Alcohol use
  • Renal failure (especially in older patients) 2

Management Algorithm Based on INR Level and Bleeding Status

1. INR Above Therapeutic Range but <5 (No Bleeding)

• Reduce or omit next warfarin dose
• Resume warfarin at lower dose when INR approaches therapeutic range
• No vitamin K required 1

2. INR 5-9 (No Bleeding)

• Omit next 1-2 doses of warfarin
• For patients at increased bleeding risk: administer vitamin K 1-2.5 mg orally
• Resume warfarin at lower dose when INR falls to therapeutic range 1

3. INR >9 (No Bleeding)

• Withhold warfarin
• Administer vitamin K 3-5 mg orally
• Monitor INR within 24-48 hours
• Resume warfarin at lower dose when INR approaches therapeutic range 1

4. Any INR with Major Bleeding

• Immediately administer:
  • Prothrombin complex concentrate (PCC) (preferred over fresh frozen plasma due to faster action)
  • Vitamin K 10 mg by slow intravenous infusion
• Hospitalize patient
• Monitor INR every 6-8 hours initially
• Additional doses of vitamin K may be needed every 12 hours based on INR response 1

5. Intracranial Hemorrhage with Elevated INR

• Immediate reversal with PCC
• Vitamin K 10 mg by slow intravenous infusion
• Consider neurosurgical consultation, especially for cerebellar hemorrhage or hydrocephalus
• If INR >10, consider fresh frozen plasma in addition to PCC and vitamin K 1, 3

Special Considerations

Mechanical Heart Valves

• For patients with mechanical heart valves and non-life-threatening bleeding:
  • Avoid rapid complete reversal if possible
  • Allow INR to fall gradually by withholding warfarin
  • Use lower doses of vitamin K (1-2 mg orally) if needed
  • Consider resuming anticoagulation within 7-10 days after intracranial hemorrhage 1

Resumption of Anticoagulation

• For patients with strong indications for anticoagulation (e.g., mechanical heart valves, atrial fibrillation):
  • Decision should be made on a case-by-case basis
  • Consult with specialists (stroke expert, cardiologist, hematologist)
  • For intracranial hemorrhage, consider resuming anticoagulation after approximately 1 week 1

Monitoring After INR Correction

• For patients continuing warfarin therapy:
  • Monitor INR daily until stable in therapeutic range
  • Identify and address causes of elevated INR
  • Consider lower maintenance dose when restarting warfarin
  • Extend monitoring intervals gradually as INR stabilizes 4, 5

Common Pitfalls to Avoid

• Administering intravenous vitamin K to patients with mechanical heart valves without life-threatening bleeding (risk of valve thrombosis)
• Using fresh frozen plasma as first-line therapy instead of PCC for serious bleeding
• Failing to identify and address the underlying cause of elevated INR
• Not monitoring INR frequently enough after correction
• Restarting warfarin at previous dose after INR correction 1, 6

Remember that patients with INR >9 without anticoagulant treatment have a poor prognosis with high mortality rates, while outpatients on warfarin with elevated INR generally have better outcomes when properly managed 2.