2nd Blood Test Today and Peter is doing well

[corrineinwa]

He started on 5mg Coumadin 3-days post op for A.Fib. After 2 days his INR was 2.8 so they skipped a dose and dropped him to 2mg.

On 4/16/09 his INR was 2.3 so no change to the 2mg the following day.

Retested today and he'd drop a little to 2.12 so they had me give him 4mg tonight and then back to 2mg tomorrow etc. He'll be retested on Thursday.

He's coping better with the low fat diet than I thought he would but it's amazing just what the promise of some icecream for dessert does (I forgot to tell it was fat free, no sugar added stuff and he can't tell the difference anyway - as long as he doesn't see the tub I'll be fine! lol).

The low sodium thing is taking a little longer to get used to but the first time he pitched a fit at the new chicken casserole recipe, I employed my parenting skills and without saying a word, I picked his meal up and fed it to the dogs. Needless to say, he hasn't made a negative comment since.

Pushing the walking has been a chore but he's made more of an effort this past couple of days. He walked close to half a mile this morning - a little less this afternoon but it was pretty warm up here today.

Now! If only he'd let me get rid of all the sticky black marks on his chest left by the tape and pads I'd be a happy bunny!

 

[ALCapshaw2]

GOOD GRIEF, WHO is managing his Coumadin?

I can't believe they are making 250% changes!!!

Have you been tracking his Exact Doses and measured INR's?
What you describe sounds like the old "Step on the Gas, Stomp on the Brakes" technique of trying to drive at the Speed Limit :-(

FYI, it takes 3 or 4 days for a pill to become fully metabolized so testing and changing doses after only One Day is MEANINGLESS.

You may want to read the "Sticky's" at the Top of the Thread Listing under the Anti-Coagulation Forum as well as AL Lodwick's website http://warfarinfo.com/publications.htm Al Lodwick sells a Dosing Guide for $5 through his website which is one of the Best Investments you can make in understanding how to make anticoagulation 'adjustments'.

It sounds like you will need to 'come up to speed' on anti-coagulation management to save Peter from the above insanity!

Be sure to document EXACTLY what Peter is being told to do (did you /he get it in writing?) and show this craziness to his Cardiologist (My fingers are crossed that his Cardiologist has read a recent revision of the C.H.E.S.T Guidelines)

'AL Capshaw'

 

[Ross]

Yet again another clueless manager. They will never get him stable doing what they're doing. I would put him on 3mg per week and test him in on the forth and seventh day. If he is in range then, that is the sweet spot. Of course, as activity and diet improves, the dosage will need to be adjusted upwards also.
I wonder if these people are ever going to learn?

Make sure he eats like he normally would. Don't buy into the myth that you must avoid high content Vit K foods like dark leafy greens and such.

As for the salt issue, Try some Mrs. Dash, Paul Prudhomme's or Tony Chachere's seasonings in place of the salt. It takes a bit of time to get used to it, but once he does, he'll be happy.

 

[corrineinwa]

I've had him home 1 week today and so far, at home, he's been on 2mg/day except for yesterday when they had me give him 4mg then back down to 2mg and get retested on Thursday.

Al,

I have recorded what I thought I had to:

4/11/09 - (3 days post op) - 5mg
4/12/09 - 5mg
4/13/09 - INR 2.8 - no coumadin
4/14/09 - discharged from hospital - 2mg
4/15/09 - 2mg
4/16/09 - INR 2.3 - 2mg
4/17/09 - 2mg
4/18/09 - 2mg
4/19/09 - 2mg
4/20/09 - INR 2.12 - told to increase dose to 4mg that day then back to 2mg

Testing again Thursday 4/23/09.

Patently, I have much to learn - now you're scaring the crud out of me. This news is upsetting - I thought the extra 2mg yesterday was just a little "tweak" to bump his number up a touch.

Wow.... I need to walk away - this has upset me - I haven't the faintest idea about this stuff and it frightens me to find out that my acceptance that they have this under control is totally wrong.

Ross - I've kept his diet exactly as it was and he's eating the green stuff. That much I already picked up. "Dose the diet not diet the dose" has been imprinted on my brain.

 

[Ross]

I've had him home 1 week today and so far, at home, he's been on 2mg/day except for yesterday when they had me give him 4mg then back down to 2mg and get retested on Thursday.

Al,

I have recorded what I thought I had to:

4/11/09 - (3 days post op) - 5mg
4/12/09 - 5mg
4/13/09 - INR 2.8 - no coumadin
4/14/09 - discharged from hospital - 2mg
4/15/09 - 2mg
4/16/09 - INR 2.3 - 2mg
4/17/09 - 2mg
4/18/09 - 2mg
4/19/09 - 2mg
4/20/09 - INR 2.12 - told to increase dose to 4mg that day then back to 2mg

Testing again Thursday 4/23/09.

Patently, I have much to learn - now you're scaring the crud out of me. This news is upsetting - I thought the extra 2mg yesterday was just a little "tweak" to bump his number up a touch.

Wow.... I need to walk away - this has upset me - I haven't the faintest idea about this stuff and it frightens me to find out that my acceptance that they have this under control is totally wrong.

Ross - I've kept his diet exactly as it was and he's eating the green stuff. That much I already picked up. "Dose the diet not diet the dose" has been imprinted on my brain.

Don't freak out. It'll get there. What your posting now vs what was said earlier makes sense, so maybe this person isn't clueless after all. It's looking to be like he's going to need 6 days on 2mg and 1 on 4mg for a total of 16mg per week. Lets just see where they go from here. He may even have to go 2x5 and 4x2 for 18mg a week. We'll see.

Big question I have is why no coumadin on the 13th? That is what set this roller coaster in motion.

 

[ALCapshaw2]

I apologize for scaring you Corrine.

Your listing is exactly how you need to keep track of his Dosing and INR. Keep it up.

It appears that they were using the 5mg as a "Loading Dose" in the Hospital.

The latest thinking is that Loading Doses (and especially Skipped Doses) only create a Roller Coaster effect in INR and most knowledgable managers no longer recommend loading doses at the start. I see now that my reaction to the use of the old Loading Dose Protocol was probably 'over the top'. Again, I'm sorry for causing you alarm.

The 4mg for One Day must have been intended as a 'bump' (albeit a 100% increase in daily dose) with the return to 2 mg. I prefer to use smaller increments to keep the INR response 'smoother'. (It's the Engineer in me.)

I think you said his recommended range is 2.5 to 3.5 but I'm not sure of that.
As long as his INR is greater than 2.0, his risk of stroke is small.
As long as his INR is less than 4.0 (or even 5.0 w/o bleeding), his risk of Bleeding is small.

Hopefully his anticoagulation manager will get him stabilized reasonably soon. FYI, Dosing is usually based on the Weekly Total and changes are based on a Percentage of the Weekly Dose.

As I said, I'm not fond of Large Swings in doses from day to day but I realize that many managers do that, especially if they like to rely on a single dose tablet and split it make adjustments.

I prefer using 2 different dose tablets (e.g. 2mg and 3mg), 1mg apart which can then be allocated to achieve the desired weekly dose and only have a 1 mg day to day change. Using a 7 day Pill Box helps avoid confusion!

Hopefully his manager will give you a suggested weekly dose once they establish his stable weekly dose.

'AL Capshaw'

 

[corrineinwa]

Al & Ross,

They want to keep Peter's INR in the 2 - 3 range.

He had intermittent A.Fib prior to surgery (4/8/09) but it became sustained immediately post-op.

I'll see if I can find out why they skipped a dose on 4/13/09 and get any other INR's - all they said was that 2.8 was on the higher side.

On 4/16/08 he had another EKG which showed a normal sinus rhythm. The hope is that he has permanently converted but either way, he'll stay on the Coumadin for 3 months.

I have a supply of 2 and 5mg Coumadins (plus vitamin K tabs on standby).

He's only been home a week today and had 2 blood tests so maybe it's too early to predict his Coumadin requirement. I'm just guessing that - I'm new to this too.

 

[Ross]

Al & Ross,

They want to keep Peter's INR in the 2 - 3 range.

He had intermittent A.Fib prior to surgery (4/8/09) but it became sustained immediately post-op.

I'll see if I can find out why they skipped a dose on 4/13/09 and get any other INR's - all they said was that 2.8 was on the higher side.

On 4/16/08 he had another EKG which showed a normal sinus rhythm. The hope is that he has permanently converted but either way, he'll stay on the Coumadin for 3 months.

I have a supply of 2 and 5mg Coumadins (plus vitamin K tabs on standby).

He's only been home a week today and had 2 blood tests so maybe it's too early to predict his Coumadin requirement. I'm just guessing that - I'm new to this too.

Don't even think of using those Vit K tablets. Use them for anything but INR unless something really really wild happens like and INR of 10 or more with bleeding. Ain't gonna happen, not on our shift anyway.

2.8 was no reason to hold. Granted, he was climbing fast, but they should not have skipped the dose, simply lowered it and continued. By skipping it, that is what threw the train off the track. I'm very happy you've been keeping track. That post made a world of difference compared to simply reading the words before. I'll recant and say this manager is not clueless and seems, at least so far, to know what she/he is doing. It's just going to take a little while to find the sweet spot. I'm betting on 18mg a week for now. That will change as his diet improves and activity increases and he'll require a tweak upwards, but when that happens, it should only be about 10% more for the total for a week.

 

[corrineinwa]

Thank you Ross.

I'd already put the vitamin K tabs away safe. I was given good instruction not to use them unless they instruct me to because of a high INR.

I'll certainly be asking why they held a dose as opposed to just lowering it. I'd know to know more about this stuff and I've also made a note about the 10% tweak thing.

But I've realised that although Peter is actually coming on leaps and bounds, I'm struggling a little all the way around right now and need to take care of myself a bit more.

I never realised just how much the old guy did until I had to pick it up and run with it. I just need to do some prioritizing and/or get some help.

I appreciate your advice Ross. Thank you again.

 

[Bridgette]

Hey Corrine, you are doing GREAT! This warfarin thing will get sorted, don't be afraid to ask questions at the clinic about why they're doing things, etc. Even though Peter might not be on it permanently, you could still get Al Lodwick's dosing chart and read up about it or go on one of the websites - Ross had a link in another thread.
Anyway, just wanted to say that you sound very calm and collected - your hubby is lucky to have you to look after him so well. Take a little rest now and later on have a read up on warfarin management - for now, recharge YOUR batteries.

 

[Jkm7]

Hi Corrine....

I'll let the experts guide the conversation re: coumadin but want to suggest a little baby oil on a cotton ball worked well for me getting the residue adhesive off my chest. I tried many other things and found that was the most gentle and effective.

Sounds like you and Peter are doing very, very well. Happy to hear it.

 

[Karlynn]

Just a hint on the Vit K. If it were me - I wouldn't take any vit K unless I was bleeding due to a very high INR. Do not let them instruct you to give him vit K for a 5.0 INR unless he's bleeding. Vit K has too much of a long term effect and will cause his INR to be hard to get in range again.

 

[dick0236]

Patently, I have much to learn - now you're scaring the crud out of me. This news is upsetting - I thought the extra 2mg yesterday was just a little "tweak" to bump his number up a touch.

Wow.... I need to walk away - this has upset me - I haven't the faintest idea about this stuff and it frightens me to find out that my acceptance that they have this under control is totally wrong.

Corrine, your husband is doing OK. DO NOT let warfarin management upset you......it is NOT rocket science. The reason your husband is given a broad INR range, 2 - 3, is because you cannot control INR to a more narrow range, nor do you have to. After looking at your "chart" it appears they are making small changes to "tweak" him toward the mid-range(2.5).
Bear in mind, that as he improves and his activity, diet, etc change, more "tweaking" may be needed to stay somewhere between 2.0 and 3.0. Always make small dosage changes to avoid the dreaded "yo-yo" effect.

I agree with Ross, hide the vit K pills. I've been on warfarin
42 years and have never had to use vit K pills to adjust INR. Usually holding a dose does the job just fine.

Continue charting his INR. I started doing this several years ago when an "internist" kept me on an INR roller-coaster for well over a year. After about a year it became apparent that the problem was his continually changing dosage. I fired him, but have continued the charting. My new doc relies on my charting more than his medical records since I keep a more detailed record. My chart*:

DATE INR DOSAGE NOTES

4/17/09 3.3 35mg(7x5mg) 2000mg amox (dental clng 4/15)

*Don't know why but my chart columns got all bunched up when I posted. Draft is OK. You get my drift. Old men and computers don't get along real well



PS: I have a good friend who was just put on warfarin for A-fib (no surgery). They were also "in awe" ....and scared to death of warfarin. The drug needs to be respected, not feared.

 

[corrineinwa]

Hey Corrine, you are doing GREAT! This warfarin thing will get sorted, don't be afraid to ask questions at the clinic about why they're doing things, etc. Even though Peter might not be on it permanently, you could still get Al Lodwick's dosing chart and read up about it or go on one of the websites - Ross had a link in another thread.
Anyway, just wanted to say that you sound very calm and collected - your hubby is lucky to have you to look after him so well. Take a little rest now and later on have a read up on warfarin management - for now, recharge YOUR batteries.

I have ordered Al's dosing chart - I'm hoping it'll help me get my head around the Coumadin thing.

I know I'll get with the programme on this. But what with Peter's surgery, caring for him on my own and keeping up-to-date with what has to done around here too, throwing Coumadin at me too just added to it all.

Sadly, I can't even rely on Peter to take his meds on schedule. I set them all out for him but he doesn't remember.

He had a stroke a few years ago and although he was left with no physical problems, he was left with some mild cognitive impairment.

Anything he did pre the stroke - maintaining the vehicles, anything mechanical or electrical is absolutely no problem but give him a new task, even something as basic as a medication schedule and he can't get to grips with it. I even tried him with my Cadex alarm watch but he's unable to associate the alarm going off with taking his meds.

We'll settle down into a routine with all of this. It's still early days - he's only been home a week and the one thing having a career in the military taught him is how to take orders. Good thing that giving them is something I excel at!

Karlynn - thanks for the hint on the Vitamin K and the "5.0 INR unless he's bleeding". I've added that information on my list.

Jkm7 - I didn't even think about baby oil - thank you for suggesting it.

Dick - Thanks for your encouraging words. As already mentioned, throwing the Coudmadin thing at me on top of everything else was difficult and without doubt, the most worrying. But I now know it's not as bad as I first feared.

Hey! I want to thank everyone. I truly don't know what I'd have done without your guidance, information and support.

And I'm sorry for turning this into an epic!

 

[ALCapshaw2]

It's become clear to me how 'hit or miss' Coumadin Dosing is immediately following Surgery and how managers need to test frequently to see 'trends' and hopefully avoid serious overdosing or underdosing.

This is not too surprising given that there is a Very Wide variation in patient metabolism and therefore a wide variation in the weekly dose needed to maintain stability.

I'm guessing that most patients end up between 2 mg and 10 mg of Warfarin (with some very high metabolizers taking even higher doses).

Since the Doctors and Nurses do NOT know whether their patient will be a High or Low or Mid-Range Metabolizer it seems to be common practice to start them at 5 mg, test frequently, and then 'ease' them in the desired direction.

"There should be a better way" you say?
Well now there IS a better way. A type of Genetic Testing has been developed which can predict whether the patient is a Fast Metabolizer or a Slow Metabolizer.

"So why isn't it used more often"?
Good Question. It is new and like all new things, takes time to become standard practice. Then there is the issue of COST. It is EXPENSIVE.

Back to the Old Tried and True method of "Trial and Error",
i.e. start with 5mg and Test Often. We've seen patients tested every day and others tested 1 to 3 times a week. It all depends on how fast their INR rises (or falls) and the knowledge and skill of the manager. I'm not sure there is a standard, at least at the start.

Fortunately, once a patient has been stabilized, it is easier to control and 'fine tune' INR with 'small' dose changes.

Now you know "The Rest of the Story" (or some of it...)

(Corrine - FYI, another of our members went on an even wilder INR / dosing Roller-Coaster Ride following her surgery only a few weeks ago. We're hoping that she is now 'easing into INR stability'. She has purchased a Home Test Monitor and hopes to go to Home Testing / Dosing once she has been stabilized and her Doctor authorizes it. You may want to consider that option...LATER!)

'AL Capshaw'

 

[Ross]

And I'm sorry for turning this into an epic!

Oh stop that, you haven't. Your just nervous like every new person is to this stuff. You'll soon be laughing at how ridiculously easy it is to dose. This is exactly why we don't understand why the medical profession can't get it and we can. It's not rocket science. It really is very simple.

Your doing all the right things. Just keep doing what your doing and this will soon seem it was just a bad dream and you'll be in happy land again.

 

[ALCapshaw2]

Another 'revelation' just occurred to me...

Some of our members reported that their Surgeons would not release them from the Hospital UNTIL their INR was Stable. (Edit: Change "Stable" to "Theraputic". Most commonly, this means getting a high metabolizer's INR to come up above the low end of their recommended range, typically 2.0 or 2.5. We have also seen a case where a patient with a High INR (overshoot the range) had to wait for the INR to come down.)

Obviously others 'push them out the door' as soon as they have ONE INR reading that is "in range", letting their Coumadin Clinic / Cardiologist / Primary Care Physician / designated Nurse / or Soothsayer worry about getting their INR stabilized.

See what we can learn about Medical Care when hundreds of Heart Patients gather together on a common Forum and share their stories. No wonder some Doc's don't like the internet!

'AL Capshaw'

 

[Karlynn]

It's good that you're asking all these questions. If you have these questions - others do to but might not ask.

Coumadin management isn't hard. It's just that the medical community likes to scare the daylights out of themselves and others - so they make it sound hard. In a nutshell: Coumadin management is about adjusting doses in order to stay within the prescribed range. For out-of-range INRs the dose is adjusted anywhere from 5 - 20% depending on how far out of range. As you all learn how your husband's body "behaves" with Coumadin, you will know what kind of dose adjustment he needs. I've been on Coumadin for over 17 years - so I'm pretty tuned to what my body does with a dose adjustment. Just last week I had a 6.3 INR. Lots of managers would panic seeing that #. I didn't. I've been there before. I've never had a bleed due to a high INR. I held one dose and took a 1/2 a dose the next night. Voila! Back in range within 3 days, no bleeding, no trauma, and not a lot of thought about what might happen. I also decided to lower my weekly dose by 10% and I'll test again in a few days to see what that has done. But still not worried.

Dose adjustments should be based on the weekly dose. Ex: someone who takes 5/day has a weekly dose of 35. If a dose adjustment is needed you do a percentage of that weekly dose. So let's say you need a 10% adjustment up to raise a low INR - you would add 3.5 mg to the weekly dose, for a total weekly dose of 38.5. 38.5 / 7 = 5.5 The new daily dose is 5.5. You can get that dose by taking 1/2 of a 1 mg tab and a 5 mg tab.

You've already learned a lot. You know MUCH more than I did at the stage you are at. Good work. Breathe deeply and relax!

 

[corrineinwa]

Today is another day and my meltdown of yesterday is behind me and after reading your replies, I realised I was just being overly anxious and that isn't helping anything.

Hopefully, Peter will stay in a normal sinus rhythm and he'll only have to do the Coumadin for 3 months. If not then we'll deal with it. At least I know it's not as fearful as I first thought.

The Coumadin Clinic have already mentioned a meter and what the criteria was. If he has to continue the Coumadin then it's certainly something I'd like to explore. Just being selfish for a minute, I'd like to get rid of the twice a week 100+ mile round trip for bloodwork.

Again - thank you.

 

[Karlynn]

Holy smokes!!! 100+ miles round trip for a blood test?