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Oral anticoagulants inhibit biosynthesis of vitamin K–dependent procoagulant factors II, VII, IX, and X, 2 reducing the coagulant potential of the blood. Future advances in this area will likely focus on evaluations of the relative merits of FFP and PCCs.
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This paper will review the evidence supporting various treatment modalities and will provide suggestions for treatment. Coagulation factor replacement is required given the need to urgently correct the INR however, vitamin K should not be forgotten since it is required to antagonize the effect of warfarin, preventing “rebound” anticoagulation after transfused coagulation factors are consumed. If the INR is in excess of 10, most experts would recommend the administration of vitamin K and, in the case of active bleeding, additional administration of coagulation factors either in the form of fresh frozen plasma (FFP) or prothrombin complex concentrates (PCC). Oral vitamin K will more rapidly return the INR to the therapeutic reference interval however, its impact on bleeding is unknown.
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In the absence of bleeding, such values may be treated with either simple warfarin withdrawal or the administration of low doses of oral vitamin K. Unexpectedly elevated INR values are commonly encountered in clinical practice.
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