Guideline recommendations for management of warfarin-associated bleeding and/or high INR

Clinical setting	2018 ASH guideline	2012 ACCP guideline
Serious or life-threatening bleeding Any INR	4-factor PCC Vitamin K (intravenous) Hold warfarin	4-factor PCC* Vitamin K (intravenous) Hold warfarin
No bleeding INR >10	(No recommendations given)	Vitamin K (oral) Hold warfarin
No bleeding INR 4.5 to 10	Hold warfarin No vitamin K	Hold warfarin Vitamin K (low dose, oral) is optional

Clinical judgment is required to assess the severity of bleeding, urgency of warfarin reversal, and need for other interventions. Refer to UpToDate for details and additional advice such as the duration of warfarin interruption and repeat INR testing.

INR: international normalized ratio; ASH: American Society of Hematology; ACCP: American College of Chest Physicians; PCC: prothrombin complex concentrate; FFP: fresh frozen plasma.

* A plasma product such as thawed plasma or FFP (approximately 10 mL/kg, depending on INR) can be used as an alternative if PCC is not available.

References:

Witt DM, Nieuwlaat R, Clark NP, et al. American Society of Hematology 2018 guidelines for management of venous thromboembolism: Optimal management of anticoagulation therapy. Blood Adv 2018; 2:3257.
Holbrook A, Schulman S, Witt DM, et al. Evidence-based management of anticoagulant therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141:e152S.

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Guideline recommendations for management of warfarin-associated bleeding and/or high INR