Warfarin Should Be Held Immediately in This Patient
Yes, hold the warfarin dose immediately and investigate urgently for active bleeding. A hemoglobin drop of 8 g/dL in one day represents clinically significant bleeding that meets criteria for major hemorrhage, regardless of the INR value 1.
Rationale for Holding Warfarin
A hemoglobin decrease ≥2 g/dL defines major bleeding according to established criteria, and this patient has dropped 8 g/dL (from 113 to 105 g/dL), which is a 7% decline in one day 1.
Active bleeding takes precedence over anticoagulation management. The primary concern is not the INR level but rather the acute blood loss indicated by the rapid hemoglobin decline 1.
Warfarin should be stopped immediately when major bleeding is suspected or confirmed, even before knowing the INR value 1.
Immediate Management Steps
Stop Anticoagulation
Discontinue warfarin immediately and do not administer the next scheduled dose 2, 1.
Check the INR urgently to determine if additional reversal measures beyond simple warfarin discontinuation are needed 1.
Assess Bleeding Severity
Identify the bleeding source urgently through focused history, physical examination, and appropriate diagnostic studies (e.g., stool guaiac, imaging, endoscopy as indicated) 1.
Monitor hemoglobin every 4-6 hours until stable and the bleeding source is controlled 1.
Assess hemodynamic stability including vital signs, orthostatic changes, and signs of shock 1.
Consider Reversal Agents Based on INR and Clinical Status
If INR is elevated (>3.0) with ongoing bleeding:
- Administer vitamin K 5-10 mg by slow IV infusion over 30 minutes 1.
- Consider 4-factor prothrombin complex concentrate (PCC) 25-50 U/kg IV if bleeding is life-threatening, at a critical site (intracranial, intraspinal, intraocular, pericardial, retroperitoneal), or causing hemodynamic instability 1.
If INR is therapeutic (2.0-3.0) but bleeding continues:
- Vitamin K and PCC are generally not indicated unless the clinical situation is life-threatening 1.
- Focus on identifying and controlling the bleeding source with local measures, transfusion support, and surgical/procedural intervention as needed 1.
Supportive Care
Transfuse packed red blood cells if hemoglobin continues to drop, the patient becomes symptomatic (chest pain, dyspnea, altered mental status), or hemoglobin falls below 7-8 g/dL depending on comorbidities 1.
Provide volume resuscitation with crystalloids if hemodynamically unstable 1.
Apply local therapy or manual compression if the bleeding source is accessible 1.
Common Pitfalls to Avoid
Do not continue warfarin "to see what happens" when faced with a significant hemoglobin drop—this represents active bleeding until proven otherwise 1.
Do not delay investigation of the bleeding source while focusing solely on INR management 1.
Avoid excessive vitamin K administration (>10 mg) as this can create a prothrombotic state and prevent re-warfarinization for days 1.
Do not restart warfarin until bleeding is completely controlled, the source is identified and treated, and the patient is hemodynamically stable 1.