EXERPT FROM: Clinical Pharmacy Anticoagulation and Anemia Service (CPAAS) Guidelines & Protocols
Kaiser Permanente Colorado
MANAGEMENT AND TRIAGE OF ANTICOAGULANT THERAPY-RELATED PROBLEMS
All complications related to anticoagulation therapy should be documented in the patient’s
computerized profile.
Bleeding Complications
Patients experiencing bleeding should be managed by CPAAS pharmacists based on the severity of the
bleeding, the patient’s indication for anticoagulation therapy, and in consultation with the patient’s
healthcare provider if appropriate. Referral to an appropriate medical facility for medical attention
should be arranged if necessary. CPAAS pharmacists should assist health care personnel in determining
proper management of the bleeding patient when necessary.
Thromboembolic Complications
Patients experiencing thromboembolic complications should be referred to an appropriate medical
facility for medical attention. CPAAS pharmacists should assist health care personnel in determining
proper management of thromboembolic complications when necessary.
Excessive Anticoagulation
Patients with excessive INR values (>4.5) who are not actively bleeding should be managed according to
the guidelines in the table. Management should be facilitated and coordinated by CPAAS pharmacists in
consultation with the referring provider when necessary. Continuing Care Physicians should be
contacted by CPAAS pharmacists whenever INR values are ≥6.0 in nursing home residents on warfarin
therapy.
Table. Guideline for the management of excessive anticoagulation in the absence of bleeding
INR Value
4.5 to 10
>10
Suggested Management
Temporarily discontinue warfarin administration, instruct the patient to
monitor for symptoms of bleeding and to notify the anticoagulation
service immediately if symptoms occur
When possible, administer vitamin K (2.5 mg orally, 1 mg intravenously,
or 1 mg subcutaneously [only if oral or intravenous unavailable])
(Alternative forms of oral vitamin K such as V8® juice, Ensure®, green tea,
etc. should also be considered when other forms of vitamin K are
unavailable)
Next INR
24 to 72 hours
12 to 24 hours
Subtherapeutic Anticoagulation
The following factors should be taken into consideration when determining the therapeutic plan for
patients with subtherapeutic anticoagulation:
1. The degree to which the INR is subtherapeutic
2. The estimated time that the INR may have been subtherapeutic
3. The individual’s risk of thromboembolism
4. The estimated time required to reestablish therapeutic anticoagulation.
Based on the above factors, CPAAS pharmacists should identify and remedy the cause of the low INR if
possible, promptly reestablish therapeutic anticoagulation, and determine whether cross-coverage with
injectable anticoagulants is warranted. When appropriate, CPAAS pharmacists should also consult with
the referring provider.