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Home | Articles | Haematology and Thrombosis | Reversal of Warfarin

Reversal of Warfarin

Last updated 18th October 2022

Life-threatening Haemorrhage (e.g. intracranial, GI)

  1. All patients, including those with prosthetic heart valves, should have their anticoagulation completely reversed (aiming for normal PT and APTT) in the presence of life-threatening haemorrhage or trauma.
  2. Stop warfarin
  3. Give vitamin K IV 5mg in 100ml glucose 5% over 15 – 30 minutes.
  4. Give intravenous prothrombin complex concentrate (Beriplex)
    • Dose according to table 1 below. Maximum dose is 5000units (200ml).
    • Reconstitute 500unit vial of Beriplex to 20ml using the sterile water and the reconstitution device supplied.
    • Infuse immediately at an infusion rate not exceeding 8ml/minute.
    • Contraindicated in patients with allergy to heparin, citrate or with suspected heparin-induced thrombocytopenia, and use with extreme caution in patients with disseminated intravascular coagulation (DIC) or recent (<1 month) venous thromboembolism, myocardial infarction or thrombotic stroke
 

Beriplex Dose Adjustment According to INR

INRApproximate Dose
2.0 - 3.91ml/kg=25 international units/kg
4.0 - 6.01.4ml/kg=35 international units/kg
>6.02ml/kg= 50 international units/kg

  1. If INR is 1.5–1.9, consideration can be given to administering a small dose of Beriplex (e.g. 12.5 International units/kg = 0.5ml/kg).
  2. Recheck coagulation status after 20 – 30 minutes and at 4–6 hours and 24 hours (or earlier if clinically indicated). Further doses of Vitamin K may be required in cases of extreme overdose.
  3. 3When haemostasis has been secured, consideration should be given as to whether anticoagulation should be restarted. If restarting anticoagulant therapy, this would normally involve prophylactic doses of LMWH initially, gradually increasing to therapeutic doses before switching to an oral anticoagulant.

Less Severe Haemorrhage (e.g. haematuria, epistaxis)

  1. Stop warfarin for 1 – 2 days, until INR has fallen to therapeutic levels and bleeding has stopped.
  2. Give vitamin K 0.5–1mg IV. Use an insulin syringe to measure required volume before adding to 100ml glucose 5% and infusing over 15 – 30 minutes. N.B.: 0.5mg=0.05ml, 1mg=0.1ml.
  3. Re-assess regularly.

Asymptomatic INR >8 or INR 5 – 8 and High Bleeding Risk (e.g. recent surgery)

  1. Stop warfarin, monitor INR, and do not restart until INR <5.
  2. Consider giving vitamin K  0.5mg IV or 2mg orally (use paediatric IV formulation orally).
  3. Check INR the next day.

INR 5–8, Asymptomatic

  1. Stop warfarin, monitor INR and restart warfarin when INR <5.

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Content updated by Dr Mark Crowther