A patient on warfarin has an INR >8 but is not bleeding. What is the most appropriate course of action?

• A. Increase warfarin dose
• B. Stop warfarin, give vitamin K orally, and restart when INR <5
• C. Administer fresh frozen plasma
• D. Wait and monitor

Answer: (B)

When the international normalized ratio is very high but there is no bleeding, the goal is to reverse the excess anticoagulation to reduce bleeding risk while avoiding unnecessary transfusions. Stopping warfarin and giving a small dose of vitamin K orally works to replenish the vitamin K–dependent clotting factors gradually, allowing the INR to fall to a safer level. Restarting therapy when the INR has dropped to below 5 helps re-establish anticoagulation safely without overshoot.

Giving fresh frozen plasma is reserved for active bleeding or urgent reversal needs, not for a nonbleeding patient with an elevated INR. Simply waiting and monitoring would leave the patient at ongoing risk of spontaneous bleeding. Increasing the warfarin dose would worsen the situation, not improve it.