What should I do with a patient taking vitamin K antagonist with a supra-therapeutic INR?

By William Aird

If INR 4.5-10 and patient not bleeding, decrease or withhold vitamin K antagonist (depending on INR level). If INR>10, and with no evidence of bleeding, oral vitamin K suggested (for example, 2.5-5 mg orally). For major bleeding, hospitalize patient, stop anticoagulant, administer vitamin K 5-10 mg IV and 4-factor prothrombin complex concentrate (PCC) (for INR 2-4, 25 units/kg, INR 4-6, 35 units/kg, and INR > 6, 50 units/kg).