5.7 How did that happen? Help !

[Ann]

First the good news. Our Cardiologist took Tim off Amiodarone this past Monday, April 10th. He started him on Toprol XL 50 mgs the next day. Really happy to be off the Amiodarone.

Now for our problem. Tim had a PT and INR draw yesterday and the results were 5.7 His weekly coumadin dose has been 57.5 being made up of 7.5mg. five days a week and 10 mg. two days. He did not eat any salad on Wednesday (which he usually has a small one each evening) Would one night without salad make this kind of difference? The cardiologist also let Tim change the time of his coumadin dose to AM with his other medications. Is there any chance taking is coumadin at 8:30 AM and having blood draw at 10:30 AM would effect the P.T?

The coumadin clinic called yesterday and told him to skip his dose for three days and come in to retest on Monday????? Doesn't that seem too much of a decrease? That would mean he would be decreasing his coumadine for this week by 25 mgs. The coumadin clinic pharmacist feels that the Amiodarone topped out at the same time as removing the amiodarone. The pharmacist also said he expects to see Tim's level on Monday to be in the 2's.

I really need your thoughts on Tim cutting the coumadin for three days?

Thank you in advance for any and all help.

 

[JimL]

The coumadin clinic called yesterday and told him to skip his dose for three days and come in to retest on Monday????? Doesn't that seem too much of a decrease?

I wouldn't even think of skipping the daily dosage for three days. If it were me -- and it has been me in the past -- I would take a smaller dosage, such as 5mg for a day or two, and then return to the normal dosage. Are there alternatives available to that coumadin clinic?

 

[terryj]

After my husband has been at 1.5 for five weeks and struggling to get to a 2.1 finally, I would take the 5.7 and go downward any day. I would say skipping 3 doses is a mistake but I will let the experts handle the advice. I just know we always have an easier time going lower than we do getting higher.

 

[Karlynn]

The coumadin clinic called yesterday and told him to skip his dose for three days and come in to retest on Monday????? Doesn't that seem too much of a decrease?

Oh lordy - here we go yet again! Where do we find these people??? I can't believe this is coming from a "Coumadin clinic".

First of all - don't freak over 5.7. That's high, but not freakout high.

I'm assuming Tim's range is 2.0 - 3.0 for his AVR. By telling him to skip his dose for 3 days they are basically saying "We'd much prefer he have a stroke than have his gums bleed a little bit." They are cutting his weekly dose by 44% - so almost in half. This will surely send his INR way below range.

I am attaching the chart from http://www.aafp.org/afp/990201ap/635.html. If you go down a bit on the page you will see this chart on how to make adjustments for an out-of-range INR with the range being 2 - 3. You will want to bookmark this site. It says for an INR over 4 withhold no dose to 1 dose (notice it says nothing about 3 doses) and decrease weekly dose by 10 - 20 %.

Now I know that amiodarone messes with the INR - but I thought it made it go higher. But since I've never taken it, I've never really paid much attention.

When I get an INR of 5 or higher, I always retest to make sure the 1st test was correct. There have been times when the first test was wrong. Was this test a blood draw or a finger stick?

Missing a salad won't do anything to his INR, much less make it go that high. Remember that Coumadin is a slow acting drug and it take 3 days for a dose to show up in the INR. Also, here is the link to Al's site where he explains how Amiodarone interacts with Coumadin. http://www.warfarinfo.com/amiodarone.htm

If Tim skips one dose and it's a 10 mg dose, that's decreasing his currently weekly dose by ~17%. If he skips a 7.5 dose, then it's 13% decrease. What days does he usually take his 10's on?

If it were me - since I tend to see-saw all over the place with big Coumadin changes, I would skip a dose, resume my daily dose and retest on Monday to see where it is. But I'll let others weigh in.

Good luck!

 

[Ann]

I should have included in my post that Tim's blood tests have been running:

March 9th - 2.0
March 20th - 2.5
March 31st - 3.4

They want him between 2.5 & 3.5.

JimL - This coumadin clinic is the better of the two available to us. Yep, I know.

TerryJ - I agree.

Ann

 

[Karlynn]

Here's the chart from that web site for the 2.5 - 3.5 range. What were Tim's doses on those dates you gave?

Do they do a venious draw or a finger stick? And when do they get you the results?

 

[Karlynn]

Has he been on the amiodarone since his surgery?

Now that he's off it, I would think that his INR will begin to go down even if he stayed on the same dose. (I did a bit of reading on Al's link ) But everyone is individual.

You certainly have good instincts in knowing that skipping 3 doses was excessive.

 

[Ross]

3 day hold is insanity at it's finniest. Guaranteed to be bottomed out by then.

At 5.7 and if there is no bleeding, I'd withhold one dose, then maybe half a dose next day, then resume normal schedule and retest in a week. Unless something can be identified for the sudden increase, I'd suspect a bad test result. It takes Coumadin 3 days to show in a blood test. Coumadin is a very slow acting drug, so whether he takes it am or pm is of no consequence and one salad isn't going to change a thing unless that salad is bowl a mile wide.

 

[Ann]

Karlynn - Thank you so very much for such an in-depth answer. Wow You have no idea how much I appreciate your time and information. I have bookmarked the site. Great site. Thank you

Tim takes his 10 mg dose on Tuesdays and Saturdays.
He did skip his 7 ½ mg dose today. The testing is done with a venious draw; they call the house the same day with the results. The clinic did not repeat the test.


March 8th he was on 7 ½ mg. every day

March 20th Tim was on 7 ½ mg ? Mon, Wed, Thur, Fri Sun
10 mg - Tue. & Sat.

March 31st ? Same dose schedule
April 13 th - Same dose schedule

Tim has been on the amiodarone since the day of surgery January 30th.

Would someone please explain how you figure out the amount to increase or decrease? I had very little sleep last night (doing taxes) my brain is having trouble with the math. Can?t imagine why

Ross - You are so funny. Salad bowl a mile wide. Thank you for your help. I really appreciate each of you and your in-sight.

I would appreciate any other suggestions as to what amout of coumadin Tim should take Saturday and Sunday. We will re-test on Monday AM.

Ann


PS- We are looking forward to getting our own home testing unit soon.
Just need to get it though the insurance.

 

[Karlynn]

If Tim took a half a dose tomorrow (Sat, so 5 mg instead of 10 and going on Ross' suggestion) along with the skipped 7.5 today, that would give him ~ a 20% decrease in his weekly dose. Testing on Monday will not give you a good picture of what that decrease did. So testing a week from his last test would probably be a better idea, once again, as Ross suggested. (Taking his regular doses on Sun - Thurs.)

From the looks of it, it appears that Tim's need for Coumadin was increasing as he healed. This is usually what happens. So the question is: What will going off the Amiodarone do and how long will it take? If Amiodarone helps to raise an INR, then going off it would lower that INR if the same dose of Coumadin is maintained. Tim may want to test weekly in order to keep a handle on just how the abscence of Amiodarone is affecting his INR. So right now he's at a high INR - assuming it's from Amiodarone (since he was just allowed to stop it) and more Coumadin than he needed in conjunction with the Amiodarone.

Be patient and hang on for a while. You will probably be messing with his dosing for a while as the affects of the amiodarone leave his system. I know other members have had to deal with this, so hopefully they'll be along to tell of their experience. You already know to recognize crazy orders when you get them . It never hurts to question orders. You either catch errors or learn more yourself - and that's all a good thing.

Home testing is a wonderful thing and I wish you luck in getting that secured. I had a very unstable INR before I began home testing. I test weekly and it has allowed me to keep a fairly regular INR. I eat and drink what I want and really only think about my INR the 5 minutes one day a week when I test.

 

[Ross]

Using his March 20th dosing. 7.5x5=37.5+10x2=20 37.5+20=57.5mg per week.

Reduce by 10%=57.5-6mg=51.5mg for the week
Reduce by 15%=57.5-9=49mg for the week
Reduce by 20%=57.5-11.5=46mg for week.

So it would look like this

Wed 7.5 Thurs 7.5 Friday skip Sat 5 Sun 7.5 Mon 7.5 Tue 10 =45mg for the week which would be a 20% reduction, which may be too much. Won't know without the test.

 

[DrAllan]

Hi

I was on amiodarone for three months. Prior to starting the drug my dosage was between 6-7.5 mg/day. After starting the amnio my dosage dropped to 3-4 mg/day. However, I was intermittently on cortisone, which also raises the INR in my case. So it was difficult to tell exactly what was going on. When not on cortisone, my required dosage increased. Basically, for myself, the dosage while on amnio was too low for the period of time when I stopped the drug. Your husband seems the exact opposite. I would look for another explanation for the rise that he exhibited.

 

[Guest]

With amiodarone there is a big difference between justt starting the drug at 200 mg per day, and taking 600 mg per day for several days. The INR is much more likely to jump up quickly with the loading dose.

 

[Ann]

Thank you Ross for the math explaination and suggestions.

Unless you Al have any other suggestions for Tims' dosage I think we will go with the suggestion of 5 mg tomorrow then resume his regular dose.

We went out dinner tonight and Tim survived , even with INR of 5.7.


This site is so wonderful. I shake to think were Tim would be next week if I had not come to all you wonderful people for help.

God Bless,

 

[Guest]

There is a report of someone not suffering any serious bleeding with an INR estimated to be about 650, so it does not surprise me that someone lived through going out to dinner with a 5.7.

 

[Ross]

There is a report of someone not suffering any serious bleeding with an INR estimated to be about 650, so it does not surprise me that someone lived through going out to dinner with a 5.7.

Perhaps that is code speak on Ann's part for saying she didn't slap him up side the head with a skillet? You know how some women can be at dinner time.

 

[Karlynn]

We could put that on the list of things to avoid if on Coumadin:
Green Jello
razors
kitchen knives
skillets

 

[Sherry]

Hi, Ann. I'm going to share my little INR fluctuation with you just as a point of comparison. I was dosing 7.5 daily and eating salads roughly 4 days per week. I went in this past Tuesday morning and found myself at a 6.7. I dropped a 7.5 dose on Tuesday, took a 2.5 on Wednesday, and a 6 on Thursday. My Thursday blood draw was a 1.6. I really feel your frustration. My cardio nurse and I are going to start playing with other sized tabs 1's, 5's, and 6's hopefully to get me more regulated.

 

[Karlynn]

Sherry, did you retest when you got the 6.7? Was it a venous draw or a finger stick? I'm suspecting that it could have been a bogus test. What had your previous INRs been?

For me personally, holding a dose tends to make me start a wild swing to the other side. (I take 10 a day on average.) When testing that high, I will decrease my next 2 or 3 days (for a 6.7 probably by 1/2). Some people (usually those that take lower doses) don't have wild fluctuations from held doses. But at 7.5, you are getting up into the area I'm in. The more Coumadin you take daily, the more quickly your INR will drop when holding doses.

 

[Ann]

Happy Easter to all!

You all are too funny. skillets

We had dinner plans last night with friends. Before all of you helped us with this NEW issue we were going to cancel, just to be on the safe side. However, after reading everyones posts, all the information, experiences you each have had and knowledge you all posess we felt very comfortable going out to eat. Considering the traffic where we live, meeting friends clear across town and it being Good Friday. This was pretty big!

Now neither of us are overly concerned or having thoughts that Tim may bleed out before his INR comes down (if indeed it was elevated) In the future we will be asking the clinic to repeat the test before we change dosage I will keep you posted as to his results this coming Monday. However, we are prepared for almost anything because of the short time between tests.

I called QAS yesterday and spoke with Lance. Which home unit do you all have (that have home units) ? Also, does everyone go with QAS or is there another company you would recommend? How long did it take to get everything approved? We had been told we had to wait until Tim had been on coumadin for 3 months before we could summit, so now it the time to start. With the recent problems, it is tempting to "just buy one" but the price is $$$$
The other side of that coin is how long does it normally take for insurance to purchase one and what hoops did you all have to jump through to have the insurance pay for one?

Thank you all.
Ann