Hematology

Answer 1 Stop warfarin therapy temporarily and recheck the INR every 1 to 2 days. The best approach to managing this patient’s condition is to stop the warfarin temporarily, recheck the INR every 1 to 2 days, and resume warfarin at a lower dose when the INR is within the therapeutic range. Fresh frozen plasma has an immediate but brief effect and is only needed in patients with an elevated INR and critical bleeding; it also creates a risk of fluid overload. Vitamin K1 (phytonadione) at any dose is effective as long as the physician is willing to wait 24 hours to correct the INR, but the administration of vitamin K1 can make further anticoagulation difficult. Therefore, vitamin K1 should be avoided in cases such as this one. If the INR was greater than 5, administration of low-dose vitamin K1 subcutaneously could be considered, in addition to stopping the warfarin. For a markedly elevated INR (> 9), 3 to 5 mg of vitamin K1 could be given orally, as well as stopping warfarin therapy. Although the optimal duration of anticoagulant therapy is unknown, most authorities recommend at least 6 months of anticoagulation for a pulmonary embolus unless there is an obvious predisposing factor, such as immobilization or surgery. Click here to return to the questions

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