7/29/2019 AF + Supratheraputic INR

1/3

Supratheraputic INR

Even if stable many months can become excessively anticoagulatedThe most common causes of overanticoagulation include interaction with another medication,wrong dosage ofwarfarin,vitamin Kdeficiency, diarrhea, heart failure, fever, and impairedliver function

Ask and check medication prescription compared to what is taken.

Few randomized studies comparing the treatment options:

Recommended management of a supratherapeutic INR

INRBleeding

presentRecommended action*

>Ther

to 5.0

No Lower warfarin dose, or

Omit a dose and resume warfarin at a lower dose when INR is in therapeutic range, or

No dose reduction needed if INR is minimally prolonged

>5.0 to9.0

No Omit the next 1 to 2 doses of warfarin, monitor INR more frequently, and resumetreatment at a lower dose when INR is in therapeutic range, or

Omit a dose and administer 1 to 2.5 mg oral vitamin K1

>9.0 No Hold warfarin and administer 2.5 to 5 mg oral vitamin K1. Monitor INR more frequentlyand administer more vitamin K1 as needed, Resume warfarin at a lower dose when INRis in therapeutic range

Any Serious or life-threatening

Hold warfarin and administer 10 mg vitamin K1 by slow IV infusion; supplement withprothrombin complex concentrate, fresh frozen plasma, or recombinant human factorVIIa, depending on clinical urgency. Monitor and repeat as needed.

INR: International Normalized Ratio; Ther: therapeutic INR range for the patient in question.

This option is preferred in patients at increased risk for bleeding (eg, history of bleeding,stroke, renal insufficiency, anemia, hypertension). (RISK OF MAJOR HAEMORRHAGE ~1%)

Adapted from: Ansell J, Hirsh J, Hylek E, et al. Pharmacology and management of the vitamin K

antagonists: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines

(8th Edition). Chest 2008; (6 Suppl):160s.

Stopping warfarin The next one to two doses ofwarfarinshould be withheld, the INR

should be monitored more frequently, and a lower maintenance dose of warfarin should bereinstituted when the INR falls into the therapeutic range.Monitor every 2 days.

If more rapid reversal is required because of the need forurgent surgery, we suggeststoppingwarfarinand administering one or more oral doses ofvitaminK(5 mg/dose) (Grade 2C). (See'Surgery/invasive procedure'above.)

IV vit K

In a prospective single-arm study, 178 patients on long-termwarfarintherapy stopped thistreatment and received 3 mg of intravenousvitamin K12 to 18 hours prior to elective surgery[54]. An INR 1.7 or 1.4 was achieved in 100 and 94 percent of the subjects on the day ofsurgery. Warfarin was re-started within 12 to 24 hours post-procedure at the previoustherapeutic dose. Four patients (2.2 percent) had procedure-related major bleeding, althoughall four had an INR 0.30 InternationalUnits/mL at

http://www.uptodate.com/contents/warfarin-drug-information?source=see_linkhttp://www.uptodate.com/contents/warfarin-drug-information?source=see_linkhttp://www.uptodate.com/contents/warfarin-drug-information?source=see_linkhttp://www.uptodate.com/contents/vitamin-k-phytonadione-drug-information?source=see_linkhttp://www.uptodate.com/contents/vitamin-k-phytonadione-drug-information?source=see_linkhttp://www.uptodate.com/contents/vitamin-k-phytonadione-drug-information?source=see_linkhttp://www.uptodate.com/contents/warfarin-drug-information?source=see_linkhttp://www.uptodate.com/contents/warfarin-drug-information?source=see_linkhttp://www.uptodate.com/contents/warfarin-drug-information?source=see_linkhttp://www.uptodate.com/contents/warfarin-drug-information?source=see_linkhttp://www.uptodate.com/contents/warfarin-drug-information?source=see_linkhttp://www.uptodate.com/contents/warfarin-drug-information?source=see_linkhttp://www.uptodate.com/contents/vitamin-k-phytonadione-drug-information?source=see_linkhttp://www.uptodate.com/contents/vitamin-k-phytonadione-drug-information?source=see_linkhttp://www.uptodate.com/contents/vitamin-k-phytonadione-drug-information?source=see_linkhttp://www.uptodate.com/contents/vitamin-k-phytonadione-drug-information?source=see_linkhttp://www.uptodate.com/contents/grade/6?title=Grade%202C&topicKey=HEME/1324http://www.uptodate.com/contents/grade/6?title=Grade%202C&topicKey=HEME/1324http://www.uptodate.com/contents/grade/6?title=Grade%202C&topicKey=HEME/1324http://www.uptodate.com/contents/correcting-excess-anticoagulation-after-warfarin?source=search_result&search=supratheraputic+INR&selectedTitle=1%7E150#H18http://www.uptodate.com/contents/correcting-excess-anticoagulation-after-warfarin?source=search_result&search=supratheraputic+INR&selectedTitle=1%7E150#H18http://www.uptodate.com/contents/correcting-excess-anticoagulation-after-warfarin?source=search_result&search=supratheraputic+INR&selectedTitle=1%7E150#H18http://www.uptodate.com/contents/warfarin-drug-information?source=see_linkhttp://www.uptodate.com/contents/warfarin-drug-information?source=see_linkhttp://www.uptodate.com/contents/warfarin-drug-information?source=see_linkhttp://www.uptodate.com/contents/vitamin-k-phytonadione-drug-information?source=see_linkhttp://www.uptodate.com/contents/vitamin-k-phytonadione-drug-information?source=see_linkhttp://www.uptodate.com/contents/vitamin-k-phytonadione-drug-information?source=see_linkhttp://www.uptodate.com/contents/correcting-excess-anticoagulation-after-warfarin/abstract/54http://www.uptodate.com/contents/correcting-excess-anticoagulation-after-warfarin/abstract/54http://www.uptodate.com/contents/correcting-excess-anticoagulation-after-warfarin/abstract/54http://www.uptodate.com/contents/correcting-excess-anticoagulation-after-warfarin/abstract/54http://www.uptodate.com/contents/vitamin-k-phytonadione-drug-information?source=see_linkhttp://www.uptodate.com/contents/warfarin-drug-information?source=see_linkhttp://www.uptodate.com/contents/correcting-excess-anticoagulation-after-warfarin?source=search_result&search=supratheraputic+INR&selectedTitle=1%7E150#H18http://www.uptodate.com/contents/grade/6?title=Grade%202C&topicKey=HEME/1324http://www.uptodate.com/contents/vitamin-k-phytonadione-drug-information?source=see_linkhttp://www.uptodate.com/contents/vitamin-k-phytonadione-drug-information?source=see_linkhttp://www.uptodate.com/contents/warfarin-drug-information?source=see_linkhttp://www.uptodate.com/contents/warfarin-drug-information?source=see_linkhttp://www.uptodate.com/contents/vitamin-k-phytonadione-drug-information?source=see_linkhttp://www.uptodate.com/contents/warfarin-drug-information?source=see_link

7/29/2019 AF + Supratheraputic INR

2/3

the time of the bleeding episode. No patient had an adverse reaction to the vitamin K infusionor a symptomatic thromboembolism during a six-week follow-up period. A therapeutic INRwas re-established at a median time of four days post-procedure (range: 2 to 11 days).

Treatment with high doses ofvitamin Kmay make it difficult to resume effective

anticoagulation withwarfarinfor days to weeks after the episode has been controlled.

Devices

Biventricular pacing is emerging as a safe and

effective treatment to improve symptoms and

haemodynamics in people with CHF. It should

be considered (with or without an implantable

cardioverter defibrillator (ICD)) in people with all of

the following:

NYHA functional class IIIIV on treatment (see

Table 1 on page four)

heart failure with LVEF 35%

QRS interval duration 120 ms

sinus rhythm.

ICD implantation should be considered in people

with CHF who meet any of the following criteria:

history of cardiac arrest due to VF or ventricular

tachycardia (VT)

spontaneous sustained VT in association with

structural CHD

LVEF 30% when stabilised post MI or

revascularisation

http://www.uptodate.com/contents/vitamin-k-phytonadione-drug-information?source=see_linkhttp://www.uptodate.com/contents/vitamin-k-phytonadione-drug-information?source=see_linkhttp://www.uptodate.com/contents/vitamin-k-phytonadione-drug-information?source=see_linkhttp://www.uptodate.com/contents/warfarin-drug-information?source=see_linkhttp://www.uptodate.com/contents/warfarin-drug-information?source=see_linkhttp://www.uptodate.com/contents/warfarin-drug-information?source=see_linkhttp://www.uptodate.com/contents/warfarin-drug-information?source=see_linkhttp://www.uptodate.com/contents/vitamin-k-phytonadione-drug-information?source=see_link

7/29/2019 AF + Supratheraputic INR

3/3

NYHA functional class II-III, LVEF 35%.

In people in whom implantation of an ICD is

planned to reduce the risk of sudden death,

it is reasonable to also consider cardiac

resynchronisation therapy (CRT) to reduce risk of

death and heart failure events if the LVEF is 30%

and the QRS duration is 150 ms (left bundle

branch block morphology), with associated mild

symptoms (NYHA Class II), despite optimal medical

therapy.

LV assist devices are used mainly as temporary

bridges to cardiac transplantation or recovery after

heart surgery.