What is the management approach for a patient with a prolonged Prothrombin Time (PT) and an elevated International Normalized Ratio (INR)?

Management Approach for PT 26.6 seconds and INR 2.2

Immediate Assessment

The first critical step is determining whether the patient is on warfarin or other vitamin K antagonists, as this fundamentally changes management and is the most common cause of these values. 1

• Check platelet count immediately to rule out concurrent thrombocytopenia, which increases bleeding risk five-fold when combined with coagulopathy 1
• Review medication history for antiplatelet agents, heparin, or direct oral anticoagulants, as these require different management strategies 1
• Assess for active bleeding (hematuria, melena, petechiae, excessive bruising, persistent oozing from superficial injuries) 2

Clinical Context Determines Management

If Patient is on Warfarin (Most Common Scenario)

For INR 2.2 without bleeding, this is typically within or near therapeutic range (target 2.0-3.0 for most indications), so continue warfarin with routine monitoring. 2

• If no bleeding and INR 2.0-3.0: Continue current warfarin dose with PT/INR monitoring at 1-4 week intervals once stable 2
• If minor bleeding occurs: Discontinue warfarin temporarily and consider oral vitamin K 1-2.5 mg 2
• If moderate bleeding: Give vitamin K 5-10 mg IV slowly 1
• If severe hemorrhage: Administer prothrombin complex concentrate (PCC) plus vitamin K 5-25 mg (rarely up to 50 mg) parenterally 2, 1

If Patient Requires Urgent Surgery or Invasive Procedure

For urgent surgery with INR 2.2, coagulation parameters should be normalized before proceeding unless it's a life-threatening emergency. 1

• For minimal invasive procedures: Adjust warfarin to maintain PT/INR at low end of therapeutic range 2
• For major surgery: Discontinue warfarin 3-6 days prior and consider bridging with heparin if high thrombotic risk 2
• Ensure operative site is sufficiently limited and accessible to permit effective local hemostasis 2

If Patient is a Stroke Candidate Requiring Thrombolysis

INR must be ≤1.7 and PT ≤15 seconds for rtPA administration; with PT 26.6 and INR 2.2, thrombolysis is absolutely contraindicated. 3, 1

• Current use of anticoagulant with INR >1.7 or PT >15 seconds is an absolute exclusion criterion for rtPA 3
• Treatment with IV rtPA can be initiated before coagulation results are available in patients without recent anticoagulant use, but must be discontinued if INR >1.7 or PT elevated 3

If Patient is NOT on Warfarin

Unexplained PT/INR elevation requires investigation for liver disease, vitamin K deficiency, factor deficiencies, or consumptive coagulopathy. 1

• Obtain complete blood count, fibrinogen, D-dimer, liver function tests, and activated partial thromboplastin time (aPTT) 3
• PT/INR may be mildly elevated in COVID-19 without indicating warfarin effect 1
• In liver disease, PT/INR may be prolonged but does not reliably predict bleeding risk 4

Reversal Strategies When Needed

Prothrombin complex concentrate (PCC) is strongly preferred over fresh frozen plasma because onset of action is rapid. 1

• PCC dosing based on INR: for INR 2-3.9 give 25 units/kg 1
• Fresh frozen plasma (200-500 mL) can be used if PCC unavailable, but carries risk of hepatitis, viral diseases, and volume overload 2
• Monitor infusions carefully to avoid precipitating pulmonary edema in elderly or cardiac patients 2

Critical Pitfalls to Avoid

• Do not restart anticoagulation within 24 hours of major bleeding without repeat imaging and hematology consultation 1
• Avoid using purified Factor IX preparations alone, as they cannot increase prothrombin, Factor VII, and Factor X levels 2
• Recognize that vitamin K administration reduces response to subsequent warfarin therapy; patients may return to pretreatment thrombotic status following rapid PT/INR reversal 2
• Do not rely on PT/INR for monitoring direct oral anticoagulants (DOACs); specialized tests are necessary 4

Monitoring Quality

• Maintain INR monitoring quality by ensuring patients are in therapeutic range >56% of time through anticoagulation clinics or computer-assisted management 1
• PT/INR should be determined just prior to any dental or surgical procedure 2
• Additional PT tests should be done when other warfarin products are interchanged or when other medications are initiated, discontinued, or taken irregularly 2