25th June 2023

Warfarin reversal guidelines

UK guidelines from the British National Formulary and British Society of Haematology advise the following regarding warfarin management in the context of bleeding or raised INR.

• Major bleeding: Stop warfarin, give vitamin K IV; give prothrombin complex (PCC) (factors II, VII, IX, and X); if dried prothrombin complex is unavailable, fresh frozen plasma can be given but is less effective
• INR >8.0, minor bleeding: Stop warfarin; give vitamin K IV; repeat dose of vitamin K if INR still too high after 24 hours; restart warfarin when INR <5.0
• INR >8.0, no bleeding: Stop warfarin; give vitamin K by mouth using the intravenous preparation orally, repeat dose of vitamin K if INR still too high after 24 hours; restart warfarin when INR <5.0
• INR 5.0–8.0, minor bleeding: Stop warfarin, give Vitamin K, and restart warfarin when INR <5.0
• INR 5.0–8.0, no bleeding: Withhold 1 or 2 doses of warfarin and reduce subsequent maintenance dose