What is the recommended dose of vitamin K (Vit K) for an adult patient with liver disease?

Vitamin K Dosing in Liver Disease

Vitamin K administration in liver disease has limited efficacy and is NOT routinely recommended for correcting coagulopathy caused by hepatic synthetic dysfunction; when indicated for specific situations (cholestatic disease, malnutrition, or diagnostic trial), the dose is 10 mg administered intravenously by slow injection. 1, 2

Understanding Why Vitamin K Usually Doesn't Work in Liver Disease

• Coagulopathy in liver disease reflects impaired hepatic synthesis of clotting factors, not vitamin K deficiency—the liver cannot produce these proteins regardless of vitamin K availability 1, 3
• Vitamin K takes more than 12 hours to begin correcting hemostatic defects and typically has only minimal impact on prothrombin time in cirrhotic patients 1, 2
• Research demonstrates that subcutaneous vitamin K does not modify coagulation parameters in liver disease, and intravenous vitamin K shows minimal effect except in cholestatic conditions 1, 4
• A 2017 study found that 62.3% of cirrhotic patients failed to achieve even a 10% decrease in INR after vitamin K administration, with only 16.7% meeting effectiveness endpoints 5

Specific Situations Where Vitamin K May Be Indicated

Cholestatic Liver Disease or Malabsorption

• Parenteral vitamin K supplementation (10 mg IV or oral) is recommended for jaundiced patients or those with cholestatic liver disease where true vitamin K deficiency exists from fat malabsorption 1, 2
• Vitamin K can be effective when patients have experienced prolonged antibiotic therapy, severe malnutrition, or malabsorption—conditions creating true vitamin K deficiency rather than synthetic dysfunction 1, 2

Diagnostic Trial to Distinguish Deficiency from Synthetic Dysfunction

• Administer a single dose of 10 mg vitamin K (IV or oral) with INR reassessment after 12-24 hours 1, 2
• Improvement in INR by ≥0.5 within 24-72 hours confirms a vitamin K deficiency component 1, 2
• No improvement indicates pure hepatic synthetic dysfunction where further vitamin K is futile 1, 3

Life-Threatening Bleeding on Vitamin K Antagonists

• For VKA-associated life-threatening bleeding: administer four-factor prothrombin complex concentrate PLUS 10 mg IV vitamin K by slow injection 6, 1
• This is the only major bleeding scenario where vitamin K is recommended in liver disease patients 6

Dosing and Administration Details

Standard Dose

• 10 mg is the recommended dose, administered either orally or intravenously 1, 2, 7
• For major bleeding on anticoagulants: 5-10 mg IV vitamin K by slow injection 6
• IV administration should not exceed 10 mg per dose to avoid creating a prothrombotic state 1

Route and Safety Considerations

• Administer IV vitamin K by slow injection (not to exceed 10 mg per dose) to minimize risk of anaphylactoid reactions 1, 2
• Anaphylactoid reactions occur in approximately 3 per 100,000 doses and can cause bronchospasm and cardiac arrest 1
• Dilute in preservative-free 0.9% Sodium Chloride, 5% Dextrose, or 5% Dextrose and Sodium Chloride Injection 7

What NOT to Do

• Do NOT routinely administer vitamin K to correct elevated INR in cirrhotic patients without active bleeding—this practice lacks evidence and is ineffective 1, 3
• Do NOT use vitamin K doses exceeding 10 mg, as higher doses create a prothrombotic state and prevent re-anticoagulation for days 1
• Do NOT use INR as a guide for bleeding risk in cirrhosis—it reflects synthetic function rather than hemostatic capacity 1
• Do NOT assume vitamin K will correct coagulopathy before invasive procedures in patients with hepatic synthetic dysfunction 1, 2

Alternative Management Strategies

For Invasive Procedures

• No correction is needed when platelet count is >50 × 10⁹/L or when local hemostasis is possible 1, 2
• For high-risk procedures where local hemostasis is impossible and platelets are 20-50 × 10⁹/L, consider platelet concentrates or TPO-R agonists on a case-by-case basis 1, 2

For Active Bleeding

• Consider targeted blood product replacement with thresholds: hematocrit ≥25%, platelets >50 × 10⁹/L, fibrinogen >120 mg/dL 1, 2
• Prothrombin complex concentrates provide more rapid INR correction than fresh frozen plasma but carry thrombotic risk (5.5% thromboembolic events) and are off-label in liver failure 1, 2
• Avoid volume overload from excessive fresh frozen plasma transfusions, which substantially increases portal pressure 1

Clinical Pitfalls to Avoid

• Patients with advanced cirrhosis (Child-Pugh B or C) and low fibrinogen (<100-150 mg/dL) have hepatic synthetic dysfunction, not vitamin K deficiency 1
• Despite abnormal coagulation tests, clinically significant spontaneous bleeding is rare in liver failure and often relates to portal hypertension rather than coagulopathy 1
• Routine correction of elevated INR with vitamin K is not supported by evidence in the absence of active bleeding 1, 3