INR 17 and Hematuria: What To Do?

Author: V. Dimov, M.D.
Reviewer: S. Randhawa, M.D.

Clinical Case 1

A 32-year-old African American male (AAM) is admitted to the hospital with a chief complaint (CC) of hematuria and back pain for 2 days.

He is on warfarin (Coumadin) 15 mg daily for a pulmonary embolism (PE) in the past. He has not had his INR checked for the last 2 months.

What is your clinical suspicion at this point?

He may be overanticoagulated with INR as high as his warfarin (Coumadin) dose (15 mg daily).

What is the cause of his back pain?

The lower back pain may be due to a back sprain but may also secondary to a retroperitoneal hematoma

What is the hematuria cause?

Hematuria is most likely due to warfarin (Coumadin) overdose.

What laboratory tests would you suggest?

Check INR/PTT
CBCD, CMP
CT abdomen

Laboratory results

INR 11
CT abdomen: no retroperitoneal hematoma


The laboratory results revealed INR of 11 (click to enlarge the images).

How much vitamin K to prescribe for therapy in this case?

The patient refused SQ or IV injections.
Vitamin K 5 mg PO x 2 was given.

How long does it take for vitamin K to decrease INR?

Vitamin K usually acts within 6 hours. This is the reason why you should check INR q 6 hrs until a desired level is reached, after you give vitamin K IV.

What happened?

The repeated INR was 1.6.
Hematuria stopped, and back pain resolved. The patient left against medical advice (AMA), realizing the risks involved if he does not follow up on his condition with a physician.

What did we learn from the case?

Vitamin K generally works fast. You have to use it with caution in patients who need anticoagulation because it can induce warfarin (Coumadin) resistance. This patient needed vitamin K because of hematuria.

Clinical Case 2

A 65-year-old African American male (AAM) with a complicated past medical history (PMH) of diabetes type 2 (DM 2), peripheral vascular disease (PVD S/P L AKA), coronary artery disease (CAD), AFib, hypertension (HTN), chronic renal insufficiency(CRI) was taking warfarin (Coumadin) 15 mg PO daily for AFib.

He had his INR checked today and the lab technician called the PCP office informing him that the patient's INR was 7. The attending asked the patient to come to the hospital as a direct admission.

When we checked our computer system the INR was actually higher than 17 (so high that it was outside the limits of the test) rather than 7 !!!


The laboratory results showed INR of 17 (click to enlarge the images)

What would you suggest at this point?

Repeat the test?
Repeated INR was 16.30 with PTT geater than 100.

That was confusing. Is it DIC?
No. Platelets were normal.

How would you treat such a patient?

Prescribe vitamin K 10 mg PO x 1.

This is faster than the FFP 4 U x 1, which he also received.

Then, check INR q 6 hrs. Type and screen 2 U PRBC, just in case there is excessive bleeding.

What happened?

The repeated INR 8 hours later was 2.99.

This an example of another therapeutic success for Vit.K. Hematuria resolved.

What did we learn from this case?

Always check the labs yourself. Do not rely on a telephone (mis) communication.

Vitamin K is effective and it works well when taken PO. There is rarely need for IV administration. Avoid giving too much vitamin K because it will induce Coumadin resistance.

According to a recent meta-analysis, oral and intravenous vitamin K are equivalent for treatment of excessive anticoagulation. Subcutaneous vitamin K is inferior to oral and intravenous vitamin K and is similar to placebo at 24 hours after administration.

References

Warfarin: The Asymptomatic Patient with an Elevated INR. Roberts, James. Emergency Medicine News:Volume 29(2)February 2007, p 13-16.
Warfarin Therapy: Evolving Strategies in Anticoagulation. AFP 1999.
Treatment of Excessive Anticoagulation With Phytonadione (Vitamin K). A Meta-analysis. Arch Intern Med. 2006;166:391-397. Link via Notes from Dr. RW
Managing a high international normalised ratio. BMJ 2011; 341:d251 doi: 10.1136/bmj.d251 (Published 19 January 2011).

Published: 02/11/2005
Updated: 04/04/2010

2 comments:

  1. how come oral vitamin k works better than FFP ? and is it the first line therapy whe there is serious bleeding? and could be the only one?

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  2. My father was not treated with vit-k but treated with FFP, platelets, and blood transfusions, he did not survive. His original INR was 15. came down to 2.1 stayed steady but just kept bleeding, aveolar hemorrage.

    ReplyDelete