A patient on warfarin has INR 6.0 but no active bleeding. What is the most appropriate immediate management?

• A Give 4-factor prothrombin complex concentrate (4F-PCC) urgently as INR > 5 mandates complete reversal
• B Administer vitamin K1 (phytomenadione) 2.5–5 mg orally and withhold warfarin temporarily ✓
• C Continue warfarin without change as INR 6 is within the therapeutic range for prosthetic valves
• D Administer fresh frozen plasma to correct coagulation factor deficiency immediately

Explanation

For a non-bleeding patient with INR 6.0 (supratherapeutic), guidelines recommend withholding warfarin and administering low-dose oral vitamin K1 (phytomenadione 2.5–5 mg). Oral vitamin K reverses over-anticoagulation within 24 hours without causing warfarin resistance, while 4F-PCC is reserved for major or life-threatening bleeding requiring urgent reversal. FFP has unpredictable volume requirements and delayed effect. Routine reversal with 4F-PCC for asymptomatic supratherapeutic INR is not indicated.

Reference: KD Tripathi, Essentials of Medical Pharmacology, 8th ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.