Coumadin and Antibiodics

[RobThatsMe]

Hi Everyone,

Well, guess I am going to be a test case here. Somehow, it seems that I have developed an infection in my left foot. I think it developed from an infected toe. However, it could also have been from an insect bite, or hopefully not, from some heart related problem. (CHF which as far as I know, I don't have)

I noticed a bump on my foot and some soreness. It also is very HOT. I went to my doctor in the morning, and he said to watch it, that it just may be an irratation to the foot, since I was climbing trees the prior week, and my foot was in a tree climber that hooked on around the area in question. If the pain and swelling continued to get worse, then he would call in a prescription for some antibiodics.

When I got home from work later that night, my foot was very swollen and sore, I started thinking infection, and then "Infection and Heart"(endocardisis), so off to the ER. They looked me over, and then still not knowing for sure what the problem is, but at the same time thinking infection too, put me on an IV antibiodic for 45 minutes, and wrote me a prescription for Keflex. (I am allergic to Penicillin). So, for the next 10 days I will be taking 4 pills a day, 500 mg each.

I tested my INR before taking the first pill, it was 2.6 (My range is 2.0 to 2.5) I will be testing it every 3 days to see how my INR reacts to the antibiodics, and will post my results.

Normal Coumadin Dosage Routine:
Tues, Weds, Thurs, Sat, Sun: 5.0 mg
Fri and Mon 2.5 mg


11/08/01 INR 2.6 (prior to meds)
11/11/01 INR 2.7 (3 days on meds)
11/14/01 INR 1.6 (6 days on meds)
I increased Thurs to 7.5 mg & Fri to 5.0 mg.
11/18/01 INR 2.3 (9 days on meds)
11/22/01 INR 2.5 ( 3 days after stopped taking meds)

Looks like everything is back within range! Happy Thanksgiving!



I know that many of us are always faced with taking antibiodics, and that it does effect our INR levels. I just thought that this would be a personal way of monitoring and posting the effects.
Having a home testing unit really helps to make this possible.

Wishing everyone good health,

Rob

[McCln]

Thanks for sharing your story and it is kind of you to post the results as time will pass on. I am a person who gets infection quite easily and also on dental work, frequently take antibiotics. And now being on Coumadin, this is all new. I just had valve replacement two months ago and any information is appricated. Thanks for sharing and keep the update regular. It will help us newbies. Thanks



Caroline
09-13-01
Aortic valve replacement
St. Jude's valve

[Perrster]

Rob,

Sorry 'bout your foot, man! I didn't think you were that close to Bullwinkle?

Great idea to start an "antibiotic" reference thread. I will post my results here early next week after my test from Amoxicillin for Bronchitis. Also doing Amoxi for dental work this month too, so I'm loaded with the stuff.

Cheers!

[hensylee]

Been wonderin where you have been. Nice to see you. Sorry to hear about your foot. Ever have gouty arthritis? Mother one time, after walking the tourist attractions of Washington, DC, developed something so sore in her heel she was unable to walk. I, too, developed something like this. It stayed and stayed but after months went away. I hope this isn't your problem, tho. The arthritis can feel warm/hot and swell but you will keep close watch, as you always do, and keep us posted on how you progress. God bless, Rob

[allodwick]

I appreciate your posting information about antibiotics. Keflex usually has little effect on the INR, but it seems that antibiotics affect people differently. I think it has to do with absorption. If someone does not absorb one very well, then it kills the bacteria in the intestinal tract. They produce vitamin K. With less vitamin K, we all know what happens to the INR.
Hope it clears up soon and I look forward to your posts. Don't quit the Keflex too soon.

[RobThatsMe]

Hi Al,

Thanks for the info. I'll test tomorrow and post my INR result. MY foot is still swollen, but it is going down some. Seems the redness and pain climbed up another 4 inches before I started to feel some relief from the medicine. So, I truly think it was an infection, as does my cadiologist, hehehehe... but, my GP still has no idea... gawd... doctors... they drive me to....Cheers!!!

As for taking the drug... I will let it run it's course. Seems I have to take it for the full 10 day period. No problem with that..

How things are going well with you,

Rob

[RobThatsMe]

Hi,

INR is 2.7 after 3 days on the antibiodic. Up only 1/10th from the start of 2.6

Rob

[allodwick]

Exactly what is to be expected.

[hensylee]

Are you continuing to repair?

[RobThatsMe]

Hi Hensylee,

<smile> Yes. my foot is much better, still some swelling, but the pain is gone. The swelling is almost totally gone too!

Thanks for asking,

Rob

[Perrster]

Yesterday's INR was 3.8.

I'm loaded with Antibiotics and not surprisingly they have spiked me up pretty significantly. Two weeks ago I was a 2.1!

Then I got the nasty ol' Bronchitis last week and the doc loaded me up with a 5-day deal of Zithromax plus 10 days worth of Amoxicillin.

My clinic nurse has adjusted my Coumadin intake to the lower 2.5's for the next four days then I go back to my regular intake.

Will test again in two weeks.

We're having some fun now!?

[Lorraine]

I had to take four antibiotics before I went to my dentist appointment yesterday morning for a cleaning. I didn't bleed much but when I went to the cardio in the afternoon my INR was 4.0. Because of that now they want me to come in again in two weeks. I believe the antibiotics in the morning did raise my level by 3:00PM. I would have thought I would have bled more at the dentist office if my INR was a 4.0 in the morning.

[Perrster]

Lorraine,

Have you (or anyone else?) ever been told to limit any particular activity or exercise routine when your INR is so high? I was just wondering if one should slow down (or speed up?) any particular activity.

I got back to the club yesterday for the first time in a week and asked myself if I should not be doing anything because of these levels. Did it anyway!

Life goes on and we gotta do what we gotta do. But we don't need to overdo anything either. But, overdo what is my question?

Hey Rob, you ol' gym rat, what do you think? Should I worry about it?

Doc just called me and said I could stop the Amoxicillin. I think allodwick said it stays in the system for awhile.

Lorraine, somebody asked me if our dual valves clicked in unison? What do think.....name that tune!?

See ya.

[RobThatsMe]

Hi Perry,

Funny you should ask, I just got back from the gym.

Well, here is my spin on the situation. Working out speeds up your metabolism, and an increased metabolism rate burns off the effects of Coumadin, so, if this is true.. then working out should help lower your INR some.

As for an extremely high INR and working out. I wouldn't want to do a heavy straining activity that may tear something internally.

Anyway, it makes logical sense to me. I have to test tonight to find out what my levels are now. It is my 6th day on the antibiodics and I owe the board an update.

Hope all is well with you, just get past these change-of-season colds and such and get healthy again soon!

Rob

[Lorraine]

Perry,

Funny you should ask that question. A co-worker and I were jsut wondering the same thing about a half hour ago. She said from what she knows, your levels can be affected by a host of things. Stress can affect it, cold weather, warm weather, I think Rain had mentioned even which way her dog layed in the flower bed ( I assume she's referring to being upset on her part). I would imagine working out would affect it one way or another too. i'll have to research that. Maybe Allodowick has an answer. As to our dual clicking valves(HEE! HEE!):D :D I have heard them most of the time in unison like havinf Stereo. How about you? Sometimes though, they're out of sinque(not sure if I spelled that right)I thibk that's when i can hear them the most!

[allodwick]

I have a patient who says that he sounds like the alligator that swallowed Captain Hook's watch.
Exercise should lower the INR. I have a patient who is in her 20's and weighed 460 lbs (no mistake). She had a blood clot in her leg and was placed on warfarin. My clinic is in a cardiac rehab and physical therapy clinic. When she was discharged from the hospital, she could only walk around the 1/20th mile track 5times. Her INR was stable on 42 mg/wk. BUT she increased her stamina and when she got up to 12 laps, she dropped her INR to 1.0. She was also down to 410 lbs. She was very adamant that she had taken all of her warfarin. So I started adjusting her doses up. She is now taking 105 mg/wk and can go 15 laps. The therapists and I keep encouraging her and talking up what she can do. She now has a smile on her face all the time and has brought a friend and has her walking too. She is a good example of exercise burning up the warfarin.
When people's health improves, they almost always need more warfarin. I get a kick out of telling them, "Oh! You are feeling better! Well then I am going to have to increase your warfarin dose!" Then I explain the reasoning. I use this in my talks to doctors too. You see a lot of heads shaking at first but then I get them nodding. Maybe they are falling asleep but I pretend that they are agreeing with me.
It is Zithromax that stays in the body for about 5 days after you stop. Amoxicillin should be gone in a day or two.

[RobThatsMe]

Hi Everyone,

Well, it is time for my 6 th day on Antibiodics INR check. I have to admit I was surprised.. and alittle shocked. Fully expecting my INR to be above 3.0, what a surprise when my results came back at 1.5 Gulp~ I checked again this morning after my evening dose, and it is now 1.6 So, I will be increasing my dose immediately.

Now, trying to figure this out, I was 2.7 3 days prior, so what has changed? Well, I am not traveling on the job right now, so I decided to get back to the gym this week, and I havce a very aggressive workout routine. Also, My lunch time meal has changed, when I workout, I eat a whole can of tuna everyday right after my workout. As I see it, even though I am on antibiodics, and they tend to raise our INR, my workouts and change of eating habits have effected my levels. I will keep you posted on my next 3 day INR check.

By the way, My recommended INR range is 2.0 to 2.5

I take 5.0 mg of Coumadin daily, except for Fri and Mon
Fri and Monday I take 2.5 mg.

I also take a 325 mg aspirin daily, and 50 mg of Atenolol.
400 units of "E"
1000 mg of "C"
and a Centrum multivitamin.

I had my aortic valve replaced, and, due to the strong force of the blood flow through that valve as appossed to the mitrial, the chance of clotting is less, and also the aspirin combiniation is a "Plus" factor to prevent clotting. I have checked with my heart surgeon, vascular surgeon, and cardiologist, all 3 agree that my range is good. However, I agree with Al and Hank. I would rather be on the high side than the lower range. I am seriously thinking of changing my range to 2.5 to 3.0

Al, what are your thoughts on this?

Thanks,
Rob

[allodwick]

Did you accidently take an extra Centrum - they have vitamin K?
Did you read about the woman who dropped her INR to 1.0 by exercising?
I keep all of my valve patients at 2.5 to 3.5, unless a doctor specifically tells me not to.
If you bleed, the remedies are apply pressure, apply ice, suture, cauterize, give vitramin K, give fresh frozen plasma, and even give more blood.
If you clot, the remedies are a new valve or therapy to overcome the effects of a stroke.
I do not agree with Jesse Ventura's, "I ain't got time to bleed." I think, "You ain't got time to deal with a clot."

[RobThatsMe]

Hi Al,

No, I didn't take any extra pills. I have been taking the drugs I mentioned in my prior post for the 20 months. My INR has always been within range, with only a few exceptions.

I think my low level may have been caused by the increase in exercise and the antibiodic.

You also mentioned your patient ranges between 2.5 and 3.5

Are these patients also taking a 325 mg aspirin daily with their Coumadin?

Thanks,

Rob

[allodwick]

Some take aspirin, some do not.

Clots that originate in the arteries are medicated by platelets. Aspirin works best on these. They are high-pressure, high-shear situations.

Clots that originate around valves are stagnation problems. Thrombin is the main mediator. Warfarin works better here.

They are not really interchangeable.

[RobThatsMe]

Hi Al,

Thanks for the update. I have a question about the stagnation and Thrombin that you mentioned. Is stagnation as much a concern for the Aortic valve. I ask this because my doctors tell me that with the higher pressure and fast blood flow the Thrombin should not be as great a concern for the aortic valve as with the metral valve area.

Thanks again,

Rob

[Marty]

Rob, I'll be interested to hear what Al says. My research and inquiries indicate the mitral valve is more difficult to replace ( my surgeon says its down deep in a hole) and is much more prone to clot and leak than an aortic valve. So as a mitral I envy you your good fortune!

[ticktock]

Lorraine, Perry, et al
Funny you guys should bring up the clicking in unison question!! Just last night, I had a dream that my valves were SQUEAKING!!
Yeah, each tick was preceeded by a squeak, like a squeaky shoe! It was so real, I woke myself up, and listened. Then, I wasnt sure enough, so got out the stethoscope. hahahhaha No squeak. Just a dream. Mine are only slightly out of sink, but remember, my fifth valve is a bit away from the others, on a conduit. Only makes sense!

[allodwick]

People with a bi-leaflet aortic valve and no complications such as atrial fibrillation can be kept at an INR of 2.0 to 3.0. However, since I seldom know (and patients often do not know) whether they have atrial fibrillation in addition to their valve, I keep them at 2.5 to 3.5.

Since the aorta is the major artery, I presume that it has the highest pressure in the body. (Remember I'm a pharmacist and didn't get all of this in school) Therefore, it would seem to me that it would be the least likely of the two positions to have stagnation problems. However, older style aortic valves such as Bjork-Shiley don't have as advanced design so they are probably more prone to stagnation. That is my best guess. As I say, I basically treat them all the same.

Ticktock - maybe you should have dreamed that you took a dose of castor oil and that took care of the squeak. That was a great story - I laughed out loud.

Marty - I received an e-mail today from a woman who says that she lives in Northern Virginia and is insured with Trigon Blue Cross- Blue Shield at $992/mo. Her husband is 63 and they want to change insurance but nobody will take them. She did not give the indication for warfarin but that he had been on it for two years.Since we helped the guy in New Zealand with his pilot's license, should we take helping them get new insurance as a project? (We might have to get capes for our crusdaes.)

I ran across a study published in 1991 where the object was to compare two levels of warfarin therapy for people with mechanical heart valves. The first group was kept at INRs of 7.4 to 10.8. (Not a mistake) The second group was kept at INRs of 1.9 to 3.6. They found that they were equally effective at preventing clots. But guess what - the people in the 7.4 to 10.8 group bled more!!! Must have been big news back then. It was published in the Journal of Thoracic and Cardiovascular Surgery.

If I am slow responding to anyone, I am going to Florida to give a warfarin talk. I'm leaving Saturday and returning Thanksgiving Day. (Very low fare that day.)

[hensylee]

Rob and Perry - how are your infections? Know you said you were getting better - but a new report? Rob, you keeping score on your INR's for future reference in here? Would be nice for others on coumadin. God bless

[RobThatsMe]

Hi Hensylee,

Yuppers... I am giving reports of my INR rollercoaster ride while on antibiodics. When I take a reading a create a new post here. BUT, I also go back into my original post, the first one on this "thread", and edit it so that all my readings will display on the original letter that I wrote.

My foot is much better, thanks. My infection is gone, but I still have to finish up the 10 days on the antibiodic. I have adjusted my Coumadin dose to bring me back up to a safe range. I was so surprised to find that mine went down. I figured it would go up on the anitibiodics. OHh well. All I can say is... I am so glad to have a home testing unit to stay on top of it.

Hope things are well with you in sunny FL,

Rob

[hensylee]

Beautiful weather - need rain, tho.

[Perrster]

Hensylee,

Thanks for checking on us.

I am now off the antibiotics. Clinic nurse adjusted my Coumadin for 4 days, and then I go back to my weekly regimine on Sunday until I retest after the holiday. Scored a 3.8 earlier this week. But I do feel one heck of lot better!

I suppose my favorite pumpkin pie will probably cause it...nah, I'll eat Thanksgiving dinner with moderation in mind!!! (My wife used to make an extra PPie just for me!)

Have a safe and Happy Thanksgiving you all.

Hey, Rob-what kind of exercises are you doing? The old f_ _ _ s basketball league starts in about a month. I expect to get a few bruises, but looking forward to being in the "game."

[RobThatsMe]

Hi Everyone,

Well, my prior reading was 1.6. That was on Weds. night. My usual dose of Coumadin is 5.0 mg per day, except on Fri and Mon. I tak 2.5 mg on those days.

My recommended INR range is 2.0 to 2.5, and I needed to get back in range. So, on Thurday I increased my dose from 5.0mg to 7.5 mg, and on Friday, instead of taking 2.5 mg, I took 5.0 mg and then continued on my usual dosage schedule.

I took my INR reading this morning and it is now 2.3 Looks like I am back in range, and I only have one more day left on the antibiodic. I will check again in 3 or 4 days to see how it reads after the medication wears off, and post my final results for the test.

I never thought that antibiodics would lower the INR. I guess antibiodics can work either way. It probably depends on the drug and the individual. Is this a true statement Al?

Hope everyone is enjoying, or in some cases had a wonderful weekend. The weather in Nashville has been fantastic!

My best to all,

Rob

[RobThatsMe]

Hello Everyone and Happy Thanksgiving to all,

I had my final INR test today to see what my level was 3 days after getting off the antibiodics. My INR tested at 2.5 Right in my range! Looks like I am back on schedule. Also, I posted all my INR results for this experiment on my first post, which started this thread.

Geezzz.... I Was kinda hoping it would be on the high side so that I could eat more salad and greens today at the Thanksgiving meal. Hmmm.... I just may anyway. Afterall, the home testing unit sure helps get it back in line! <smile>

Wishing everyone a warm and wonderful day with your loved ones and families.

Happy Turkey day!!

Rob

[allodwick]

Rob,
I think you are right about the antibiotics affecting people differently. My theory has to do with absorption. If people do not absorb them well, the bacteria in the intestine are killed faster. These bacteria produce vitamin K -- so we all know what happens then.
Of course, some of the antibiotics have a direct effect on the warfarin.
Anyhow, my theory accounts for the variations. It would also explain why some people get diarrhea or yeast infections from antibiotics and others do not.
Thanks for keeping us informed and letting everyone know the value of self-testing. Many could print this out and show it to their physicians.