Goodnough et al outlined a protocol for rapid reversal of a prolonged INR as a result of warfarin therapy or severe vitamin K deficiency. The authors are from Washington University and Barnes-Jewish Hospital in St. Louis.


Patient selection: markedly prolonged INR



(1) vitamin K

(2) fresh frozen plasma

(3) recombinant Factor VIIa (rFVIIa)

Bleeding Status


none or minimal

10 mg vitamin K, intravenous or subcutaneous, discontinue warfarin therapy

mild to moderate

10 mg vitamin K IV, FFP 15-20 mL per kg, discontinue warfarin therapy

life threatening, intracranial

10 mg vitamin K IV, FFP 15-20 mL per kg, rFVIIa 20 µg/kg IV (dosage range for rFVIIa 20-90 µg/kg) , discontinue warfarin therapy



• rFVIIa therapy should only be used when absolutely necessary due to cost ($1,500+ per milligram).

• Administration of rFVIIa alone will not provide the other factors necessary for hemostasis (Factors II, IX, X).


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