What to do with a patient on aspirin with an elevated INR of 2.18?

Management of a Patient with Elevated INR on Aspirin Therapy

The patient with an elevated INR of 2.18 while on aspirin (Ecosprin) should temporarily discontinue aspirin and have their INR monitored more frequently until it returns to an appropriate therapeutic range based on their clinical indication. 1

Assessment of Current Situation

• The patient's INR of 2.18 with APTT of 57.0 seconds and PT of 27.20 seconds indicates anticoagulation that may be excessive for a patient on aspirin therapy alone 1
• This combination of elevated INR and aspirin therapy increases bleeding risk, especially gastrointestinal bleeding 1
• The therapeutic INR range depends on the specific clinical indication for anticoagulation, which is not clearly specified in this case 1

Management Algorithm

Step 1: Determine the cause of elevated INR

• Check for recent medication changes or additions that could interact with anticoagulants 2, 3
• Assess for acute illness, particularly diarrhea which can significantly elevate INR 2
• Evaluate for decreased oral intake or dietary changes affecting vitamin K consumption 2
• Rule out liver dysfunction or other pathological causes of elevated coagulation parameters 1

Step 2: Immediate management based on clinical indication

• For a patient on aspirin alone without intended anticoagulation:

  • Temporarily discontinue aspirin (Ecosprin) 1
  • Monitor INR daily until it returns to normal range (<1.5) 1, 4
  • Investigate underlying cause of elevated INR 1

• For a patient with intended anticoagulation (e.g., mechanical valve, atrial fibrillation):

  • If the target INR is 2.0-3.0, the current level is acceptable but aspirin increases bleeding risk 1
  • If the target INR is lower (e.g., 1.5-2.0 for elderly AF patients), reduce anticoagulant dose 1
  • Consider discontinuing aspirin if not specifically indicated 1

Step 3: Long-term management based on clinical indication

For coronary artery disease:

• If aspirin is indicated for coronary disease, consider resuming at a lower dose (75-81mg) once INR is in appropriate range 1
• For patients requiring both anticoagulation and antiplatelet therapy, target a lower INR (2.0-2.5) to reduce bleeding risk 1

For mechanical heart valves:

• Target INR 2.5-3.5 for most mechanical valves 1
• If aspirin is added, maintain INR at the lower end of the therapeutic range 1, 4
• Monitor INR more frequently with concomitant aspirin use 5, 6

For atrial fibrillation:

• Target INR 2.0-3.0 for most patients 1
• Consider lower target (1.5-2.0) for elderly patients (>75 years) 1, 4
• Avoid aspirin combination unless specifically indicated for coronary disease 1

Important Considerations and Pitfalls

• Concomitant use of aspirin and anticoagulants significantly increases bleeding risk, especially gastrointestinal bleeding 1, 6
• Poor INR control with high variability is the strongest independent predictor of reduced survival in patients requiring anticoagulation 1, 6
• Patients with renal failure are at higher risk of intracranial bleeding when anticoagulated 6
• Bleeding with a therapeutic INR often indicates an underlying pathological cause that should be identified and treated 1
• Avoid intravenous vitamin K in patients with mechanical valves who are not actively bleeding, as this increases risk of valve thrombosis 1