There have been a few cases of supra-therapeutic INR in the Sinai ED recently, and at the request of one of our superstar interns, below you will find a brief set of recommendations regarding Supratherapeutic INR. The following bolded recommendations are for your patients who have no clinically significant bleeding: (These are recommendations based on American College of Chest Physicians clinical practice guidelines.)

Under 5: Hold the Next Dose

INR 5-9: Hold the Next 2 Doses. If patient is low thromboembolic risk, can also give small dose of Oral Vitamin K (1-2.5mg PO)

INR >9: Stop Warfarin, give 2.5-5mg PO Vitamin K. 


The more difficult issues come into play when your patient has significant bleeding. Your most readily available options will be 4 factor PCC, 3 factor PCC, and Fresh Frozen Plasma (FFP).

KCentra (4 factor PCC, inactive form) can be administered rapidly compared to FFP, and will subsequently lower your INR faster. This should be your go-to medication while resuscitating a hemorrhagic patient with a high INR. It is considered preferable to the activated 4 factor PCC or the 3 factor PCCs due to lower rates of thromboembolic events. TXA and Desmopressin are also potential adjunctive therapies for patients with significant bleeding and/or platelet function. Don’t forget: TXA can be topicalized or nebulized depending on your source of bleeding! This is a great option to avoid systemic medication for an externally localized bleed.

Remember: When dealing with these patients, balancing their risk of further bleeding must be weighed against the condition that requires them to be anti-coagulated in the first place.


1. Ansell J, Hirsh J, Hylek E, et al. Pharmacology and management of the vitamin K antagonists: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 2008; (6 Suppl):160s.

2. Protocolized warfarin reversal with 4-factor prothrombin complex concentrate versus 3-factor prothrombin complex concentrate with recombinant factor VIIa.AUBarton CA, Hom M, Johnson NB, Case J, Ran R, Schreiber M SOAm J Surg. 2018;215(5):775. Epub 2018 Jan 5

3. Segrelles Calv G, et al. Inhaled tranexamic acid as an alternative for hemoptysis treatment. Chest. 2016;149;604.

4. Solomonov A, et al. Pulmonary hemorrhage: a novel mode of therapy. Respir Med. 2009;103;1196-1200. 3. Hankerson MJ, et al. Nebulized tranexamic acid as a noninvasive therapy for cancer-related hemoptysis. J Palliat Med. 2015;18;1060-1062.