Patients at increased risk of bleeding include 3: Consideration of individual clinical parameters (eg, fall risk, blood pressure, comorbidities) and the patient’s innate sensitivity to warfarin are important when deciding when treatment should be restarted. Warfarin should be restarted, if necessary, when the INR falls below 5.0. INR 4.5-7.9Īsymptomatic patients with an INR that is only slightly above the therapeutic maximum can often be managed simply by omitting their usual warfarin dose and increasing their frequency of INR monitoring. Measuring the INR every 24 hours is usually sufficient unless clinical deterioration occurs. Regardless of which treatment is used, it is important to increase the frequency of INR monitoring until it returns to the desired range. Where patients are asymptomatic (ie, not bleeding), their INR is used to determine the need for treatment. Local guidelines may also exist, such as those for hospitals in the north of England on which this article is based. Recommendations for managing patients who have been over- anticoagulated are included in the ‘British National Formulary’. Any requirement for warfarin reversal therapy can serve as an opportunity to review whether warfarin treatment is still necessary for the patient. Clinicians also consider how quickly and to what extent the anticoagulation needs to be reversed. Which option to use depends mainly on the severity of a patient’s bleeding, or risk of bleeding, at the time of treatment.
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