A patient on warfarin for DVT prophylaxis has an INR of 8.5 with minor bleeding (nosebleed). The appropriate management is:

• A Continue warfarin at the same dose and monitor; the INR will self-correct
• B Administer fresh frozen plasma (FFP) immediately regardless of bleeding severity
• C Hold warfarin, give oral vitamin K (1–5 mg), recheck INR in 24 hours ✓
• D Administer 4-factor prothrombin complex concentrate (4F-PCC) for rapid reversal

Explanation

For supratherapeutic INR of 5–10 with minor (non-life-threatening) bleeding, current guidelines recommend holding warfarin and administering low-dose oral vitamin K (1–5 mg). Oral vitamin K lowers INR within 24–48 hours and is preferred over IV vitamin K (which carries risk of anaphylaxis) for minor bleeding. FFP and 4F-PCC are reserved for life-threatening or intracranial hemorrhage requiring immediate reversal. For INR 4.5–10 without bleeding, simply holding the dose may suffice; minor bleeding warrants accelerated correction. The dose of oral vitamin K should be kept low to avoid over-correction making the patient subtherapeutic.

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

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Written and medically reviewed by the StethoPrep medical team.