Way Out of range

[imhayley]

I tested yesterday and my pt was 6.9
My range is 2.5 - 3.5. They told me to hold a dose, dont bump anything and test again today. Today was 5.6. Told the same thing again. Isnt 6.9 way too high? Maybe I need to trust the coumiden nurses more but 7 days after my ohs I was re-hospitalized for 8 day for blood transfusion as my inr/pt was 11.9. Im just wondering if this is normal or if I should have been given vitamin K? I know very little at this point on what happens when its too low or high unless its at 11.9 then I know that one but at 6.9 thats not dangerous ? Any info will help Thanks!!!!!!!

[ALCapshaw2]

FIRST, you need to understand that PT and INR are NOT the same thing. It's like apples and oranges. SO, what are you really measuring and reporting?

'AL Capshaw'

[gijanet]

but when we were in the hospital, Katie's INR hit the 6 mark. They had us hold two doses, which was the WRONG thing to do as she dropped to the one range. I think holding one dose would have been fine for us, but again, this is just us and I am in no way an expert. I hope you get regulated soon. Many hugs. Janet

[JimL]

I have an excellent coumadin nurse, and I trust what she says. But then, I've been training her for the past four years. After the INR test, she asks me what I'm going to take, as I set my own dosage.

I think the patient is the best one to manage the coumadin. Measure your coumadin intake by the week, not by the day. Then change your own weekly dosage, generally by not more than 10%. My dosage has stayed fairly steady for quite some time at 44 or 45 mg per week, although my INR fluctuates quite a bit, still within range.

When you check your INR, you are measuring one point only; you know what your INR is at that moment, but not whether it is going up or going down. When you check one day at 6.9 and the next day at 5.6, that would seem to indicate your your INR is on a downward hill. When the effect of skipping a dose hits three days after you skipped the dose, that will bring the INR down more.

I'm sure Al will have better things to say.

[Emma]

As far as I can tell, different people react differently to warfarin dosages. I mean, Chloe is VERY sensitive to it (if thats the right expression) and even a tiny change in her dosage can make her INR shoot up or down and very quickly too - much faster than the 2-3 days that warfarin is supposed to take to have any effect on the INR. I don't know why and the doctors didnt even believe me until they made a couple of mistakes with her and ended up with INR's of 1 on her!
When her INR hit 7.5 a while back, even the doctors, having now seen how she reacts to it, agreed with me that we shouldn't hold a whole dose as she would shoot down into the 1's. We gave her 1mg instead of her normal 3 then 2mg the next night, then back to normal the 3rd night and when I retested her she was back down to an INR of 3.6. So even holding one dose would have been too much for her.
I guess its a trial and error thing until you get used to how your body reacts. I'd be very surprised if anyone wanted to give you vit K for an INR of 6 though and the fact its 5.6 now would say its settling - I'm sure when you retest that in a couple of days you will be back within normal range as you continue with your normal warfarin/coumadin dose.
My lord, I can waffle when I'm bored can't I?!
Sorry - hope your INR settles soon
Emma
xxx

[Karlynn]

I'm sure you mean INR - not PT. If your clinic or office is still using the term PT, and giving you INR #'s - ask them to correct their terminology so as not to confuse patients.

I've found that holding doses is highly relative to how much Coumadin you take. The more you take, the faster your INR drops. I take and average of 10 a day. Holding a dose would really drop my INR fast. Someone who takes 3 a day would not see nearly as fast a drop with one held dose. If your INR was 6.9 yesterday and 5.6 today - it's not because of the held dose. Your INR was already on the way down. Your INR will not reflect the held dose for 3 days. Jim is right, it's better to take a look at your weekly dose total and adjust that. I've posted a chart below for recommended adjustments for the 2.5 - 3.5 target range users.

Taking Vit K at 6.9 is not warranted unless you're having a bleeding incident.

[imhayley]

Okay I did just re-dye my hair so bare with me;)
I take 5.0mg of coumiden daily except for m,w,f when I take 2.5. Last month it was the exact opposite and I was low (my INR's right?) so they reversed the dose. Things were okay for 3 wks then all of a sudden the 6.9 test. Im so happy that I didnt have to get any vitamin K or do anything. The reason I worry is because I talk to a total of 5 different coumiden nurses (depending on who is working that day in the clinic vs. out with patients with the Doc. You never know who you will get and YOU CANNOT (why why why?) request to talk to a specific nurse. TOO many hands in me coumiden pot. Yesterdays nurse now tells me to skip another dose (last nights) take a 2.5 thursday and test again friday and call with results. SHE is the nurse who was monitoring me when I ended up 11.9 (oh and did I mention she is so cold as ice to deal with and even the other nurses apologize to me for her rudeness!!!) and in the hospital. She wants me to take 2.5 all week and thats it. She is screwing things up I think and yes I am taking over here and monitoring what doses they are giving me as to try and dose myself eventually. If I call tomorrow and SHE is the nurse I will hang up as I would rather die than deal with her again! Thank You for all the information you have given me as I cant even get this much info from them. They are TOO busy too busy toooooooo bizzzzeeee.
tick tick tick
thanks again

[Nancy]

Why not just say, "I don't care to deal with you. Please put your supervisor on the phone. I do not feel you have a good grasp of how to deal with Coumadin and in addition, you are extremely rude." And then tell the supervisor exactly what you have told us about how she is with you, and how she screwed up.

You really don't have to accept incompetence or rudeness either. Don't be a wimp! :)

[Cris N]

Hayley,
I'm so sorry you're having such a terrible time with this. I do need to ask the obvious though. They've had you bouncing your dosage around - is there any chance you took the wrong dosage on several days? I know I've done it. With 5 mg one day and 2.5 the next it's easy to get messed up and take the wrong amount. I now use a 7 day pill container & load it up after my weekly testing double checking my dosage card to make sure I put the right ones in the right day... and then check it again.

Cris

[McCln]

How many days between new dosage change and the INR reading? If it is every three days, not enough time given for the dosage to work. You need to talk to the supervisor and get the straight on the INR testing. Someone is not doing it right or something. Good luck.

[Rich]

I have the same question as Caroline.
It sounds like they have you testing too soon after a dosage change.
It takes about three days to see a change, and it sounds like they are having you re-test after only two days.
In the meantime are there other reasons for this 'roller coaster' ?
Are you being consistent with your eating and excersise?
Rich

[imhayley]

Okay well here I go. Yes I use a 7 day pill container as Im extremely anal about most everything. I MAKE SURE I take the correct dose every single time as I dont want to ever have another 11.9 reading. Yes they held 2 doses (last night and the night before) and tonight I took 2.5 (lil blue guy) and am to test in the morning and call in the results. I am no whimp in fact quite the opposite and am working very hard on my addiction to confrontations. (true story) I back down to Nancy because I havnt the bail money. She is lucky I am working on my issues and Im using her as my test dummy to see how patient I can be. Ive plotted her death in my head for 5 months now and thank goodness my anti depressants are working because Im ready to move on.;) In fact she (the rude one) asked me a few days ago if the anti depressants were helping and I told her "Yes I havnt plotted your death for 3 days now!" HA! HA! I swear that was my moment of glory! ALL the other coumiden nurses help me and are awesome and yes I did stop abrubtly with my excerise program....could that make it go haywire? Other than that I havnt change a single thing as I am so aware of everything I see a shrink weekly to try and lighten up. I will let you know what my INR's are tomorrow and what Im instructed to do over the weekend then we can compare notes.
Thank everyone so very much for your input in means more than you can ever know as you see what I deal with at my coumiden clinic and here Im NEVER put on hold. Thanks again!!!!!!!!!!

[geebee]

Hayley,

You said you took 2.5 mg and that it was a "little blue guy". I must say that concerns me because the 2.5 mg tablets should be green. The blue tabs are 4mg tablets.

Any thoughts on this one? Are you sure of the pills you are taking?

[bvdr]

Hayley, I agree with Geebee on the color of tablets. Even the generics of coumadin I have used have always been color coded the same.

Abruptly stopping exercise affecting your INR? You betcha it will. More exercise usually equates to more warfarin, decreased exercise then decreased coumadin. hange in routine. This is not true on a day to day basis but with a consistant change in your exercise routine.

[imhayley]

Well I didnt know that stopping excersise would effect things. Yesterday I was able to start again and had the best day mentally that Ive had in 5 months. Okay the 2.5 is green Im sorry I said blue and yes Im positive absolutely without doubt (I am the queen of "what if" ) that Im taking the correct dose on the correct day. I alredy tested this morning and Im at 2.4 (range is 2.5 - 3.5) so Im curious to see what the coumiden clinic will say. If Nancy is working I will ask to speak to another nurse as this is a 3 day weekend and Im not going to spend it obsessing on weather she gave me the right info or if she is going to miss dose me and kill me. Thanks for your input as I'm ALWAYS looking for answeres and am so blessed to have them come from you.

[JimL]

If your INR has been 6.9, 5.6, and 2.4 on three consecutive days, doesn't that mean that your INR is decreasing? Does it mean it's decreasing too far? I would suggest that you have skipped enough doses, and you should be sure to take a dosage today. I suggest that you aim at taking the same dosage every day, as much as possible.

I have a prescription for 5mg and 6mg tablets, which allows me to take nearly the same dosage every day to yield 44 or 45 mg per week. If you are at 25 or 27.5 mg per week, you could consider getting a second size so that you can stay as consistent as possible: 4mg every day, for example, with a 2.5mg here or there to bring the weekly total where you'd like it.

[imhayley]

I took 2.5 last night as instructed (only held 2 doses) and ususally my dosing schedule was 5.0 everyday but mon, wed, fri. Those 3 days I take 2.5. Thats all I know. I did what they said and its not coming out right. How freakin long does it take to get regulated. Until they call me today I dont know what I take tonight. Thanks Jim for you input and yes I agree that its now decreased again below target range. Up down Up down ...story of me life!





If your INR has been 6.9, 5.6, and 2.4 on three consecutive days, doesn't that mean that your INR is decreasing? Does it mean it's decreasing too far? I would suggest that you have skipped enough doses, and you should be sure to take a dosage today. I suggest that you aim at taking the same dosage every day, as much as possible.

I have a prescription for 5mg and 6mg tablets, which allows me to take nearly the same dosage every day to yield 44 or 45 mg per week. If you are at 25 or 27.5 mg per week, you could consider getting a second size so that you can stay as consistent as possible: 4mg every day, for example, with a 2.5mg here or there to bring the weekly total where you'd like it.
:eek:

[Karlynn]

A clinic or office that is testing you daily and making adjustments when you are dealing with a high INR, is going to have you rebounding all over the place. Have they really tested you 3 days in a row? If so, it tells that they don't know what they should know about the management of Coumadin and you will not become "stable" with that a type of management.

My guess is that you were 2.4 yesterday and it was showing some of the 1st skipped dose. If I was a betting person, I'd bet that today's is going to be even lower.

[imhayley]

Okay so today I was told to go ahead with the usual dose of 5.0 everynight and 2.5 mon wed fri. Re test on the 28th of Dec. Now heres my next question (and last...sorry to be a pain in the coumiden area) Since I have my own test kit isnt it wise to just check it to see what it is any time i want to feel re-assured? They get real mad at me because Im a bit, should I say paranoid, and want to check it more to be sure. However every time Ive done the curiosity check its way high or way low so I call the clinic. Should I NOT test in between the time they tell me to or is it better to know in case its way screwed up and im in danger. Gosh Im so scared of this crap I hate it! Acceptance is the answer to all my problems and Im having a real hard time getting accepting here. Thanks....happy holidays!

[geebee]

Hayley,

I test (using my INRatio) every one to two weeks depending on how time gets away from me. I also test every 6 months at the lab just to keep my cardio happy for comparison purposes.

If you have a home tester, why don't you just use that instead of having lab tests? I think you are getting too many results and changes are being made too quickly which is why you are bouncing all over the place.

[allodwick]

Warfarin is a very slow acting drug. It works by slowing the body's production of clotting factors. It does nothing to the clotting factors that are already in the blood. So it takes 3 to 5 days to see the full effect of a dose. Therefore, when you test more often you are not seeing the effect of the last dosage change. So if you change the dose more often than once per week you are probably just like a puppy chasing its tail. You may find a level that is in range sheerly by chance, but it will probably not stay in range because of all the dosage changes whose effects are not being seen yet. The quickest way to get into range is to pick a dose that seems to have worked and take it for a week and see what happens. Then you tweak the dose up or down by about the equivalent of one day's dose per week. Example: if you take 35 mg per week and the dose is a little high then take the dose down to 30 mg per week. (5 mg daily except for 2.5 mg on Mon and Fri). If the dose is too low tweak it up the same way (5 mg daily except 7.5 mg on Mon and Fri). Breaking the pills in half works just fine.

In medicine you should never run a test unless you know what you are going to do with the results. In the case of warfarin it is unnecessary to test too often because you almost always need to wait a week from the last dosage change to see what the fnal result will be. The exceptions are INRs below 1.7 and greater than 8 -- or if you are actually bleeding.

[imhayley]

hi Geebee and yes I use an inratio and only that. I havnt tested in the lab for quite some time and am well aware that the readings on both come out a bit different. This is why Im able to test when I want yet the curiosity of where Im at (on the inr chart) gets me at times so I test just to see.


Hayley,

I test (using my INRatio) every one to two weeks depending on how time gets away from me. I also test every 6 months at the lab just to keep my cardio happy for comparison purposes.

If you have a home tester, why don't you just use that instead of having lab tests? I think you are getting too many results and changes are being made too quickly which is why you are bouncing all over the place.

[imhayley]

Thank you so much for your help I appreciate it greatly. I shall step away from the InRatio machine and ONLY test when they tell me too. I know very little about warafin and am learning a great deal on your site (Thank YOU again) and hopefully will be a pro in no time. RIght now my coumiden is regulated by my cardiology office where they have the coumiden clinic. They told me NOT to self dose until they get it regulated. I was doing fine with the dose I was on weekly and was testing every 2-3 weeks....but the curiosity got the best of me and that is when I tested and ended up in the 6.9 range. I really appreciate your input and I will stop (say a prayer for me please to be able to do this) testing "just to see" as I can see im only causing more problems for myself by doing so. Plus my lil fingers tips are a hurtin too.
Thanks again really I can use all the help I can get and your site is great!





Warfarin is a very slow acting drug. It works by slowing the body's production of clotting factors. It does nothing to the clotting factors that are already in the blood. So it takes 3 to 5 days to see the full effect of a dose. Therefore, when you test more often you are not seeing the effect of the last dosage change. So if you change the dose more often than once per week you are probably just like a puppy chasing its tail. You may find a level that is in range sheerly by chance, but it will probably not stay in range because of all the dosage changes whose effects are not being seen yet. The quickest way to get into range is to pick a dose that seems to have worked and take it for a week and see what happens. Then you tweak the dose up or down by about the equivalent of one day's dose per week. Example: if you take 35 mg per week and the dose is a little high then take the dose down to 30 mg per week. (5 mg daily except for 2.5 mg on Mon and Fri). If the dose is too low tweak it up the same way (5 mg daily except 7.5 mg on Mon and Fri). Breaking the pills in half works just fine.





In medicine you should never run a test unless you know what you are going to do with the results. In the case of warfarin it is unnecessary to test too often because you almost always need to wait a week from the last dosage change to see what the fnal result will be. The exceptions are INRs below 1.7 and greater than 8 -- or if you are actually bleeding.
:o

[allodwick]

I'm diabetic, so I understand about the sore fingers and the temptation to test to see what happened. But the insulin does work faster so you went to test every few hours.

[imhayley]

Well I took the dosage I was given for 6 days and tested today with a 6.2. Now Im being told to hold tonights dose and test again tomorrow. Okay I give up....Isnt there a way to just dose myself and be in charge of this instead of crackhead coumiden nurse who doesnt know what shes talking about. I asked her a question re how long coumiden stays in your system (and brought up a few pointers that you people here have taught me to let her know she could stop talking to me like I was born yesterday) and she said she didnt know and the coumiden rep had just left and hmmm she will have to ask him the next time she sees him.....DUH SHOULDNT A NURSE HANDLING MY LIFE KNOW THIS??? maybe im too sensitive and paranoid (like they treat me) or maybe Im not getting the right info and I need a professional....a REAL professional.
tick tick tick
nag nag nag:mad:
getting crazier by the minute here

[allodwick]

If she doesn't know that basic fact about warfarin, how can she be in charge of monitoring it?

If she depends on a sales rep for all of her information, how can she be a good nurse?

If she doesn't know how to look up a fact in the PDR, how did she get to be a nurse?

[Karlynn]

Testing tomorrow after holding tonight's dose will not tell you anything about how the held dose fully affects your INR. It will not tell this crackhead nurse anything either. Testing on Saturday will give you that answer.

Refer to the chart I sent you. It says for an INR greater than 5.2 - withhold 1 to 2 doses - decrease weekly dose by 10-20%.

Look at your weekly total - don't look at your daily dose. Decrease it by 10-20%.

Holding tonight is reasonable. You need to take a look at how your INR's react to held doses and decide whether holding another day will be too much. Either way, I would then, if it were me, do the 10-20% decrease of the weekly dose.

I tried rereading the posts here but didn't find it. Did your INR swing too low yet, or has it always been too high since you started this thread?

Make sure you are keeping records of your INR and dose. I keep a graph chart so I can see trends.

[imhayley]

Well I held the dose last night and tested this morning 6.6
Im going in the wrong direction. Yesterday 6.2 today 6.6 and NO coumident was taken last night. Karlynn I never recieved your info you are refering to but would love to know where I can get that chart if possible. Today of course I will be dealing with another nurse so I have no idea WTF is going to happen. Is it dangerous to be in 6's for over a week?
Im afraid to just tell them to, well you know the word, and just take over myself but this is very scary to me and well I guess that makes me a scaredycat. I ask her if I should go to the lab and have them draw just to be sure that things were okay and she told me no that it wasnt necesary but if I had to have lab work done any time soon that I might do it then. WHAT? Does that make sense? Today when I call in my results I will tell them again that I dont feel confident with how things are going and how I can do it by myslef.:eek: :eek: :eek: :eek: :eek:

[imhayley]

She is the ONE nurse who scares me most and normaly I wont talk to her and will wait until then next day but since my INR's are so high I didnt want to take any chances. I told her yesterday that if she asks me one more time If Ive been drinking (been clean and sober for 9 years) Im going to mess with her and tell her "why yes Nancy in fact I just came home from the bar 5 minutes ago!~" ANywho Allodwick Im in Reno so if you can inform me of any other options for managing my coumiden I would be grateful!~
thanks so much and have a ticking day!




If she doesn't know that basic fact about warfarin, how can she be in charge of monitoring it?

If she depends on a sales rep for all of her information, how can she be a good nurse?

If she doesn't know how to look up a fact in the PDR, how did she get to be a nurse?
:p

[Karlynn]

Go to this site http://www.aafp.org/afp/990201ap/635.html (and save it in your Favorites)

Scroll a little over a third of the way down to a chart entitled: Altering Warfarin Dosage to Achieve INR of 2.5 to 3.5

Today's test is not going to tell you one bit about how your held dose last night is affecting your INR. What it is telling you is how the dose you took 48 to 72 hours (and more likely 72 hours) ago is affecting your INR. The skipped does last night MAY begin to show up if you test tomorrow, but Saturday will tell you for sure.

You cannot continue to make adjustments such as skipping doses and expect to see results the very next day. Coumadin is a SLOW acting drug and doesnot show affects in your INR 12 to 24 hours later.

I don't think you are ready yet to handle your own dosing, but I also don't think you should continue relying on this doctor's office. You need to find a Coumadin Clinic in your area. I'd really like to know how many of their Coumadin patients have had stroke or bleeding incidences.

Your INR will never become stable if it continues to be managed in this way.

If you call in your INR today and the nurse makes yet another adjustment - like saying "skip 2 more days" - they don't know their @$$ from a hole in the ground.


Go to this site and see if you can locate a Coumadin Clinic in your area. www.acforum.org

[Karlynn]

Please try and get hooked up with one of these today.

ST. MARY'S RISK REDUCTION CENTER
Phone: (775)770-7400
343 ELM STREET, SUITE 308, RENO, NV 89503



RENO HEART PHYSICIANS
Phone: (702)333-7410
85 KIRMAN AVE. #202, RENO, NV 89502


VAMC ANTICOAGULATION CLINIC
Phone: (702)786-7200
1000 LOCUST ST., RENO, NV 89520

[JimL]

The INR is constantly going up or down; an INR test measures where it is at one particular point in time; but knowing that one particular point in time does not say whether the INR is going up or down. Apparently, yours is going up, right, since you tested at 6.2 and then 6.6? But the rising INR is the result of the coumadin you took three days ago, plus whatever other factors there are.

I suggest that you manage your own coumadin, but be nice to the coumadin nurses, at least most of them. Listen to what they say, and then decide for yourself what you're going to take. They can think that they're managing your coumadin if they want, but you need to take charge of it. My INR was 3.5 this morning, and my gem of a coumadin nurse, Debbie, said that I am "perfect." I believe her, even if no one else does.

[Mary]

. . . and my gem of a coumadin nurse, Debbie, said that I am "perfect." I believe her, even if no one else does.

I believe her.:) :)

[Jimmy]

Dear imhaley,
Yes 6.9 is high but not "rush to the hospital" high, I had a quadrupal bypass and a St. Judes mechanical aortic valve done on Dec. of 2004 and since then my INR has never been stable I have ranged from 1.3 to 7.8 (twice at 7.7 and 7.8) the first time I was 7.8 my doctor told me to go and get a shot of vitamine K which was a mistake I found out by reading different web sites, the next time he told me just to miss a dose (he must have been reading the same sites) I self medicate because he never calls unless it hit the 7 mark again, but anyway I would miss one dose get checked again and adjust your coumadin doseage by 10 to 20% for the week either up or down depending what you are. I think stress has a lot to do with your levels as well and as far as the click,click,click it drives me nuts as well it's also like a reminder every night what you have, but at least we know it's working. Good luck, try not to worry.
Jimmy

[imhayley]

I agree with everyone. I am VERY nice to the nurses as they hold my life in their hands at this point and dont want to make them mad. Secondly the 3 choices of management are great however Reno Heart Physicans told me I WAS OKAY AND IT WAS IN MY HEAD (the a-fib and the mvp with regurg) and fired me as a patient when I begged to differ. This has been so hard for me to over come because HE WAS WRONG!!!!! and less than 2 months later im in the OR having OHS. Okay sorry so anywho......today nurse Scott told me to hold another dose tonight and call tomorrow for the plan of action. I know that holding doses wont reflect for a few days. I asked them why they are testing me daily and they said they need to see how low it went because in fact it does (according to nurse Scotty Potty) go lower by holding a dose and that will tell them what to dose next by having me test right after holding a dose. Did I just make any sense? I am going to just put on my helmet and wait it out in me padded room. That way Im safe:eek:
I will check out the other options for coumiden clinics but you do understand that this is AT MY cardiology office (the coumiden clinic) and so I dont understand what the problem is. These are the same nurses that work with the docs they just rotate daily in and out of the clinic to make it fair I guess but i dont friggen know. I do know that pretty soon Im not going to care anymore as this whole damn thing is just not working for me. The ticking the freaking coumiden crap the despression the crying the worrying the "what ifs" the PTSD I now have.......time to now thanks all. sorry.

[imhayley]

:eek: Todays INR's 2.9
So that means that in a day or too I will be even lower becasue it takes a few days for the dose or the "NO" dose to show its level. So hopefully by Saturday my INR's will be in the negative and the coumiden clinic will of course be closed for the holiday and I will just sit home and freak out as usual. Happy New years!
I may not be much.......but Im all I think about.:eek:

[allodwick]

HAYLEY, I just sent you a PM but I will post it here too. I trained the staff of Dr. Michael Bloch (pronounced Block) to manage warfarin and my aunt is pleased with his clinic. Give him a call. The number is in the PM.