does this sound right?

[Lynlw]

I don't know alot about coumaden, but this was on another board i am on and (that earlier today i mentione good place to learn about home testing is here) she is really new at this, but I'm not sure if this sounds like the best plan, if it isn't I'll email her and ask her to please come here


--------------------------------------------------------------------------------

Well, test #2 proved to be too much... I am now off coumadin for 4 days, then will have one 2mg tablet starting again on Monday; then test Tuesday. This isn't going to be an easy thing - is it...

[Ross]

NO That is completely wrong! Holding for 4 days will have her completely bottomed out. We need to speak to her and get more information as to her dosing and such. Can't tell you how to fix it until I know how it's broken.

[Lynlw]

that's what I thought , I just sent her a PM asking her to come here.

She has had a rough time w/ her heart lately, she lives in Alaska and went to both cal and i think chicago for her repair. and had post op problems
a week or so ago she was admitted for blood clots in her lungs and had Afib
and was started on coum and lovenox
here was the post from Monday

Well, after only 3 days of coumadin, I am at the perfect level (2.5). So, I can stop the shots of lovinox (yay), and the dr dropped my dose from 5 mg to 4. I get tested again on Thursday to see how it is going.

I Really hope she comes here. I think she needs you guys, lyn

[Ross]

I would assume she is high risk, which would put her range at 2.5 to 3.5. Why on earth would someone tell her to drop the dose just beginning to get in range? They are going to kill her. She needs to find someone that knows what they are doing. If she clots and has afib, I'd rather see her at the high end around 3.5.

Lyn don't get me wrong, I don't know it all, but I know enough to manage my own dosing and what this person is doing to her is wrong.

[Lynlw]

I know you guys know probably more than alot of docs, (which is sad and scarey too) Anything i learned I learned here, 'just in case' but the little i do know was sending up all kinds of red flags, thanks, I hope she does join, Lyn

[Alaska]

1. Went to ER Thursday night - turned out to be blood clots in lungs; was given a shot of lovenox
2. Started 5 mg coumadin on Friday; continued lovenox.
3. First INR test on Monday - results were 2.5. Stopped lovenox. Dose reduced to 4mg.
4. My range is 2-3
5. Went today for INR test #2; INR results 8.0!
6. Doctor directed stop for 4 days; on Monday take a 2mg tablet & Tuesday test

As you can see - this is all new to me. We have no cardiologist in this town. Pretty frustrating. I am going to order a INRatio Self Test machine so that I can test regularly.

I apologize for the spelling - like I said, I'm a newbie!

[geebee]

Welcome Alaska.

Is the only reason you are on coumadin is because of blood clots or do you have a mechanical valve?
In any case, stopping for 4 days is an outrageous direction. Even from an 8.0, you will be down to way below range by the end of 4 days (probably around 1.0 which is a non-coumadin user).
The most I would hold is 2 doses then pick up with 3 or 4mg and retest on Tuesday.
With blood clots in your system, you cannot afford to have your INR too low. I would much rather be at 8.0 than below 2.0 even without clots.

[Ross]

I cannot see how it could climb to 8.0 in 4 days. I think the test result is wrong. Holding for 4 days is going to bring you back to coagulated and with your troubles, you don't need that. At most, I would hold maybe two doses and I hesitate at that because I think the test was wrong, and then start the 2mg. It takes 3 days for a dose to show in the test.

For the most part, what he/she is tellling you is correct except to hold for so long. They are afraid of bleeding, we are afraid of clotting and stroking out. Our Manta, You can replace blood cells, you cannot replace brain cells.

If you decide to home test, you'll need a prescription for the machine. All the necessary paperwork can be downloaded from the link below:

http://www.ptinratio.com/patient_how_to_get.asp

I'm under a tornado watch and the storm is on top of me now. I have to get off until it passes. I'll be back to address whatever as soon as possible or someone else can on my behalf.

[Alaska]

No mechanical valve. A-fib/flutter & blood clots is my reason...

[Ross]

Here is a link to an article that will help you understand more with dosing charts, how to manage low and high INR etc.

http://www.aafp.org/afp/990201ap/635.html

[Georgia]

Hey, Alaska! Glad you dropped by.

You need to go to www.warfarinfo.com - a site written by our resident coumadin expert, Al Lodwick (a pharmacist & runs a coumadin clinic). There's an incredible wealth of information there.

Now - about this holding for 4 days. You inr will fall 50% by holding one day. Guess what happens in 4 days - you'll be back on lovenox (or on a heparin drip if you have more clots). 8 is really high; but 0 is really low. I'll let other experts recommend just what you should do.

You MUST understand that doctors for the most part don't have a clue about managing coumadin. They don't understand how it works, how long it takes to get in the system, or how to dose it. Further, coumadin patients are nothing but trouble for them. YOU have to learn about this quirky treatment and how to manage it.

Many of us spend our lives arguing with our docs or simply not doing what they tell us to. We use the dosing charts on Al's website, and get guidance here.

We all feel that recommending holding 4 days constitutes malpractice - it'll leave you completely un-anticoagulated. Coumadin takes about 3 days to get metabolized; so what on earth is a doctor thinking by taking you off it for 4 days?????

Enough of the soap box. But I'll tell you this - if I hadn't tripped over this website, I'd have been seriously at risk many times due to mismanagement of my coumadin.

[Alaska]

Thanks Ross & Gina. I found online a dosing chart and it pretty much said to stop for 2 days too. I think I'll call the doc tomorrow and ask for a new reading just to be sure. I'm thinking she is probably doing the four days because of the weekend and not being able to test.

Ross - good luck with the tornado warning! Yikes...

[geebee]

We just finished a horrendous thunderstorm and tornado warning here but all is past now. Hope Ross is OK.

Alaska,
I think redoing the test makes a lot of sense but, even if a second test shows in the 8 range, I would still not hold more than 2 doses. Then take 3 or 4 mg/day until you can test again which I assume would be Tuesday because of the holiday.
Best of luck to you.

[Ross]

First round went through pretty uneventful.

How is your diet? What do you eat? Please tell me they haven't told you to stay away from greens and everything containing Vit K.

Friday to Monday 5mg=20mg then dropped to 4mg for Tuesday through Friday=16mg for a total of 36mg for the week. Minus 20% would put you at 29mg for the week with 4mg per day.

2mg X 7 days= 14mg which is more then a 50% drop from where you were.

How soon do you get the test results? Same day?

[Alaska]

They gave me a pamphlet of all the vit k foods, and said to either be consistent eating them or stay away. I'm not sure how to be consistent though - how many times can you have broccoli or asparagus? I must say I'm confused. Seemed like the easiest way was to stay away...

[Alaska]

Oh, and diet... fairly healthy; not much fast food at all (1 am mo maybe - then it is Subway). Ie: last night - chinese food - chicken, veggies, noodles, rice (ok, not so good); night before - a mexican casserole with gr beef, olives, tom sce, cheese & tortillas; breakfast: cereal; lunch: sandwich; 3 times a week - salad; don't get as much fruit as I should.

I drink a couple glasses of milk a day. I take a multi without vit K.

[Alaska]

Yes, I get the results immediately @ the dr office.

[Ross]

They gave me a pamphlet of all the vit k foods, and said to either be consistent eating them or stay away. I'm not sure how to be consistent though - how many times can you have broccoli or asparagus? I must say I'm confused. Seemed like the easiest way was to stay away...
Mantra #2 Dose the diet you eat, do not diet the dose of the drug. Eat all you want too and adjust for that diet. I'm anything but consistent. Al refers to me as "Street People" because of poor diets, but I have no troubles keeping in range. I eat lots of broccoli, brussel sprouts, asparagus, salads, spinich you name it.
Diet plays a very small role in INR management, but if your not getting any Vit K, then it can be a problem.

[Alaska]

OK - so how do I learn all I need to learn? I noticed the article that you referred to was 1999, anything more current, or is it pretty much status quo?

What do you do when their is no cardiologist in your town (or even close by)?

All this is on a bit of a rush basis - I'm supposed to be getting married in the Caribbean on 6/24. We are planning on being gone for almost a month. I'd like to get this all worked out/figured out before we leave on 6/16. I can take my test kit with me, and hopefully by then will know what I'm doing????

[Ross]

That page I posted is pretty much it. Again, visit Al Lodwicks site at www.warfarinfo.com and read as much as you can. He also has a chart to use that he sends out for a $5 donation to his site. It's not rocket science and I don't know why Doctors have such hard time understanding it, but they do. Maybe it's to simple for some of them and they aren't use to something so uncomplicated?

The big thing for you right now, is getting you in range, getting you stable and then making minor adjustments of 10% -/+ over a week to keep you there. Once you have a handle on that, things will smooth out for you. Notice I said over ONE WEEK, not every 3 or 4 days. They need to look at the total you've taken over a weeks time and adjust from there. As is, they'll keep you seesawing.

[Alaska]

If I were to use a chart (I found), it would say to do this: (my newbie thinking shows I'm sure)

miss 2 doses
go down 1mg/d for the week 7 mg total in weekly dosing) - that would put me at 3mg

I'm just worried that my body is hypersensitive and the 3 will be too high. I thought I jumped up to INR 2.5 too fast (after 3 pills), and jumped from 2.5 to 8 too fast (after3 more pills)

I also thought of going back in for another test today, and asking them write a lab order for me at the lab tomorrow. That would be after the 2 missed doses - what INR should I expect, and what doseage should I start with? Should it be based on the 8.0 score thinking above; or be based on what the INR says?

I guess I should buy the chart. So, if you have a home test machine, do you test weekly, then adjust? Daily? Adjust?

I'm sorry for all of the questions - us newbies need a place like this to learn.

[Ross]

I think you should hold 2 days, start with 2mg per day as suggested because I too, am concerned that 5 possibly 10mg total put you at 2.5, IF THAT TEST was right also. I don't see that happen very often, but it has in the past. Some people metabolize the drug faster then others.

After 2 missed doses, you should be just about in range if not slightly high still.

I test weekly and seldom have to make any adjustments. I have CHF that acts up now and then and causes mine to drop because of hepatic congestion. Once your in range and stable, you'll seldom have to do anything and if you do, it will only be by 10% up or down.

Don't test today and tomorrow, just tomorrow after it's been a two day hold. Testing that close together will tell you nothing except maybe that the test was wrong, but it's not necessary and can wait until tomorrow.

[Alaska]

So, what should my test tomorrow show, and should I start on the 2mg tabs no matter what the level?


My body is pretty sensitive and responds "well" to drugs (as I've been learning recently). My dosages are pretty small compared to most.

Here is what I'm currently on:
Metoprolol 12.5 mg twice a day
Lisinopril 5 mg day
Amiodorone (200 mg day) - now stable, not going up or down at the current time due to a-fib

I was on aspirin, but they took me off when I started the blood thinner.

Here is my litiny of issues:
Coronary Fistula between the coronary sinus & coronary artery. This was embollized with coils in Chicago. The surgery is supposed to have a little BIT of clotting over the coils, followed by tissue growth. In my case, I had a lot of clotting that backed up in the circumflex cutting of oxygen to the vessels there - hence heart attack. And, my last little trick was the blood clots in the lungs. This has all been going on since the surgery in April, however with all the testing etc - it started to some extent in Oct.

[Ross]

Amiodorone (200 mg day) - now stable, not going up or down at the current time due to a-fib

I think I know why your so high now. Amiodarone! http://www.warfarinfo.com/amiodarone.htm

With a two day hold, you should be in range or just slightly above. That is o.k., if you start the 2mg tomorrow, it's not going to show in a test until after Monday.

Clotting is a big deal to you and if you held for 4 days, you would certainly be in danger. Holding 2 days will cut that 8.0 down to around 3.5 or so. Real close anyhow. You DO NOT want to fall below range like would happen if you followed their directions, unless you have more lovenox and can cover yourself for another week or so.

[Alaska]

I know the amiodorone effects levels, and wondered if that is how I got so high so quickly.

So, if I'm around 3.5 tomorrow, should I do a full 2 mg, or partial tab?

[Christine]

Hi Alaska... thougth I'd throw my 2 cents in here.. Ross hit on the head about mananging the coumadin, as did everyone else who posted.. I learned real quick I needed to take control of the drug vrs my drs.. they're good and better then some in the past, but i'm not the patient type and tired of arguing over dosing (when they usually give in to me anyway) like most, i self test and self dose.. there some who are fine with skipping a dose but not more then 1.. i'm not one of them.. last month I was sick and had INR of 6.7 - even cutting my dose in half (which is what i normally do for a few days if I why I was high) I nose dived to a 1.3... as with everyone else.. I'd rather be high then remotely low.. i'm still bouncing back and forth in my range.. but i'll get there..

in the beginning, i used to think I had watch everything I ate with vit k to the point of insanity.. now, like Ross and others, I still eat my veggies, but I don't go overboard.. i'm not the committed type to eating salads everyday, so i don't even try and will turn one away if had one earlier in the week.. it's all about moderation..

my personal feeling.. any DR who tells you to skip more then one day does not know what he is doing.. I personally will not skip anyway, but cut in half if need be..

hang in there.. you've come to the right place for support.

Chris

[Karlynn]

Welcome Alaska - looks like I missed a lot of action here. 3.5 is not too high. Most of us don't give it much of a thought if we're at 4 and at 5 we'll treat ourselves to a dark green salad.

I think I recall Al Lodwick telling us that the usual response to an INR when doses are held is to drop in 1/2 for a 48 hours hold.

Another mantra: doctors fear bleeding, patients fear clotting. Your doctor's responce to your 8.0 isn't all that unusual unfortunately. Unfortunately, clots can be much more catastrophic in their damage than bleeding. (relating to the blood cell, brain cell mantra)

[Ross]

I know the amiodorone effects levels, and wondered if that is how I got so high so quickly.

So, if I'm around 3.5 tomorrow, should I do a full 2 mg, or partial tab?
I would do the full 2mg because remember, it's going to take 3 days for it to show up in a test. In essence, you'll be putting a stop to the major plunge that is occuring because of holding.

[Alaska]

I have a call into the dr about getting her to write orders so that I can be tested this weekend at the hospital so we have a clue what is happening. I also said I worried about stopping for 4 days, and that the info I've been able to find says 2 days, so we will see what she says.

[Ross]

Even starting the 2mg tomorrow, your still going to be dropping, but it's not going to be a crash. We want to keep you anticoagulated. That is the goal, not to have you start all over again.

[allodwick]

One thing to add. You must not become pregnant while on warfarin. If you get to 6 weeks and are still taking it, the baby can have malformations - usually of the face.