Management of Elevated INRs

INR Symptoms Recommendations
INR > therapeutic < 5 No significant bleeding Omit a dose
Resume at a lower dose
RTC in 1 week
INR 5-6 No significant bleeding Omit a dose
Consider 500mcg po Vitamin K
(available OTC)
RTC in 1 week
INR 6-9 Consider ER referral if high risk for bleed Omit a dose
Consider 2.5mg po Vitamin K
Check INR daily
INR > 9 Consider ER referral if high risk for bleed Omit a dose
Consider 5mg po Vitamin K
Check INR daily
Any INR Serious or life-threatening bleed ED referral
 

  • Increase or decrease oral Vitamin K administration based on the clinical situation.
  • Parenteral Vitamin K should only be used for life-threatening bleeding and is therefore not appropriate for outpatient use.
  • Use the recommendations for the next lower INR range in the following situations:
    1. High initial INR – First 7 days are rapid suppression of Factor VII 
      (the faster the INR goes up, the faster it comes down)
    2. High thrombosis risk – First 30 days following venous thromboembolism
    3. Active malignancy
    4. Antiphospholipid Antibodies (APLA)
    5. Femoral Bypass Graft