What is the immediate management for a patient with a severely elevated International Normalized Ratio (INR) and Covid-19?

Management of Severely Elevated INR in COVID-19 Patients

For patients with severely elevated INR and COVID-19, immediate management should include vitamin K administration and consideration of prothrombin complex concentrate (PCC) for active bleeding, while maintaining platelet count above 50 × 10^9/L and fibrinogen above 1.5 g/L. 1

Initial Assessment and Monitoring

• Assess for active bleeding - this is the primary determinant of management urgency and approach 1
• Monitor PT, D-dimer, platelet count, and fibrinogen levels regularly as these parameters help determine prognosis in COVID-19 patients 1
• Recognize that COVID-19 patients commonly develop coagulopathy which can complicate management of pre-existing anticoagulation 2, 3
• Note that abnormal PT or APTT is not a contraindication to thromboprophylaxis in COVID-19 patients without active bleeding 1

Management Algorithm for Severely Elevated INR with COVID-19

For Actively Bleeding Patients:

1. Administer vitamin K (oral or IV depending on severity) 3
2. Consider prothrombin complex concentrate for life-threatening bleeding 1
3. Maintain platelet count above 50 × 10^9/L 1
4. Keep fibrinogen above 1.5 g/L 1
5. Target PT ratio <1.5 (note: PT ratio is not the same as INR) 1
6. Consult with transfusion services early due to potential blood product scarcity during pandemic 1

For Non-Bleeding Patients with Severely Elevated INR:

1. Administer vitamin K (preferably oral unless INR is extremely high) 2, 3
2. Hold vitamin K antagonists (e.g., warfarin) temporarily 3, 4
3. Monitor INR frequently as COVID-19 can cause significant fluctuations in anticoagulation effect 2, 3
4. Maintain platelet count above 25 × 10^9/L 1
5. Consider switching from vitamin K antagonists to LMWH for the duration of COVID-19 illness 3, 4

Special Considerations in COVID-19

• COVID-19 infection creates a prothrombotic state that can persist even after recovery, potentially requiring extended anticoagulation 4
• Patients on warfarin may experience unexpected INR fluctuations due to COVID-19 infection, concurrent medications, and altered liver function 2, 3
• Despite elevated INR, COVID-19 patients may still develop thrombotic complications due to the strong prothrombotic state 2, 4
• Drug interactions between COVID-19 treatments (e.g., azithromycin) and warfarin can significantly impact INR control 2

Prophylactic Anticoagulation After INR Correction

• Once INR is corrected to safe levels, prophylactic dose LMWH should be initiated in all hospitalized COVID-19 patients without contraindications 1
• LMWH is preferred over other anticoagulants in COVID-19 due to its anti-inflammatory properties and more predictable effect 1
• For patients previously on warfarin, consider maintaining on LMWH until COVID-19 resolution to avoid unpredictable INR fluctuations 3, 4
• Patients with D-dimer >6 times upper limit of normal may derive greater mortality benefit from anticoagulation 1

Pitfalls to Avoid

• Do not assume elevated INR provides protection against thrombosis in COVID-19 patients - the prothrombotic state may still predominate 2, 4
• Avoid interpreting PT results as INR when managing COVID-19 coagulopathy (they are not equivalent) 1
• Be cautious with vitamin K dosing, as overcorrection could increase thrombotic risk in an already prothrombotic condition 2, 3
• Remember that COVID-19 patients may have delayed thromboembolic complications even after apparent recovery 4
• Monitor for liver dysfunction which may further complicate coagulation management 3, 5