This patient should be treated with oral vitamin K for a supratherapeutic INR without evidence of active bleeding. Elevation of the INR beyond the desired therapeutic range is common in patients taking vitamin K antagonists. Recommended management depends on the level of INR elevation and whether active bleeding or bleeding risk factors are present. In patients without bleeding, management involves withholding warfarin and possibly administering oral vitamin K, depending on the level of INR elevation. For a supratherapeutic INR less than 5.0, withholding warfarin and restarting at a lower dose are usually adequate. For an INR of 5.0 to 9.0, a similar management strategy is appropriate, although administration of 1 to 2.5 mg of oral vitamin K is reasonable in patients at risk for bleeding. In patients with an INR greater than 9.0, such as this patient, administration of 2.5 to 5 mg of oral vitamin K is indicated to more rapidly reduce the INR to the desired range.

In patients with serious bleeding, active reversal of anticoagulation is indicated regardless of the INR level. Use of intravenous vitamin K and 4-factor prothrombin complex concentrate (PCC) (or 3-factor PCC and fresh frozen plasma [FFP] or recombinant activated factor VII) is preferred. FFP alone is an option if factor concentrates are unavailable. These treatments are not indicated in this patient who does not have evidence of active bleeding.

Because the risk of bleeding increases with the level of INR elevation, not providing additional treatment for this patient with a significantly supratherapeutic INR would be inappropriate.