For patients on vitamin K antagonist therapy with INR below 4, which action is recommended?

• A. Treat without interrupting medication
• B. Immediately interrupt and hold anticoagulant
• C. Switch to a DOAC
• D. Need urgent reversal with vitamin K

Answer: (A)

When a patient on a vitamin K antagonist has an INR below 4 and there’s no bleeding, the safest and most appropriate approach is to continue anticoagulation without interrupting the medication. The reason is straightforward: the current level of anticoagulation is not excessive, so stopping or reversing it could raise the risk of thrombosis in someone who needs ongoing protection against clotting. Reversing with vitamin K is reserved for significant bleeding or when INR is dangerously high, not for values under 4. Switching to a DOAC isn’t indicated just because the INR is low, and interrupting therapy would unnecessarily expose the patient to clot risk. Monitor and, if needed, adjust the dose at the next scheduled check.