INR > target, no bleed
- INR 5–8: withhold 1–2 doses, restart at lower dose
- INR >8: withhold + vitamin K 1–5 mg PO
Minor bleed
- Vitamin K 1–3 mg slow IV
- Re-check INR at 6–24 h
Major bleed
- Stop warfarin
- Vitamin K 5–10 mg slow IV
- PCC (Octaplex/Beriplex) 25–50 U/kg by INR
- FFP only if PCC unavailable
