6.1

[cocoalab]

Okay. I mentioned this in a previous thread but would like to know your opinions. Andrew has an INR of 6.1. Funny I had to wait days to hear it was low but they called his doc and she called us the same day.

We were told to skip last nights dose and test today. I'm here near the lab so I am doing it. Will there even be a noticible difference this soon? (About 12 hours from missed dose to test) Then it was suggested to skip tonights also if there is no change. I worry he will drop like a rock- remember last week when he was 1.6 or so?

And how high is his risk of a significant bleed at this level? Remember his range is 3 to 4.

So many questions. This is my third trip out here since yesterday. First the blood test, then I was at the ER getting x-rays on his brothers hand- broken and now back for cardiac rehab and another blood draw down at the lab.

And of course we are planning on going out of town Friday and we are going to Noah's Ark Friday. When things are busy they just get busier!

 

[Bina]

Skipping last night's dose was fine, and I would take half a dose tonight, you don't want to create a drastic swing.
Testing today won't show the skipped dose from yesterday. Changes can take 2-3 days to show up on the test.
Your clinic is really running you around.....

 

[ALCapshaw2]

Have you discussed Andrew's INR MIS-management with his Cardiologist? As I said the last time Andrew's INR spiked, his Cardiologist NEEDS TO KNOW how poorly his Coumadin / INR is being managed.

It's pretty clear that *someone* doesn't know how to manage his Coumadin / Warfarin. Testing only 12 hours
after a dose change is most likely too soon and will give a meaningless / worthless result.

What have YOU done to entice his managers to get his INR results back to you on the SAME DAY? Changing doses 2 days after a test is almost surely going to result in Wildly Swinging INR results as you are seeing.

Do you have a listing of his Daily Doses, INR Test Results, and Dose Changes recommended by his Nurse Manager(s)?

Do you have a copy of AL Lodwick's Dosing Guide ($5 through his website www.warfarinfo.com)?

I hope you will get his Cardiologist involved in straightening this mis-management out this time. Otherwise, it would appear that you will only get 'more of the same'.

 

[catwoman]

Wendy:

Do you have any guesses as to why it's jumped to 6.1? Has Andrew been told to overcompensate by taking larger-than-usual doses -- or done so on his own?

What is his usual dose and what has he been taking prior to this INR of 6.1?

 

[perrypiratesdad]

Testing that soon will not show anything. The half life on warfarin is 2.5 days. Tell the clinic and doctor to get a clue!

 

[Karlynn]

Don't know what testing today will tell, other than it's on it's way down. The size of his dose should give you a clue whether you need to hold tonight or take half or do nothing. The more Coumadin he takes, the faster his INR will drop.

I had a 6.1 a month or so ago. I was taking 76/week (a fairly large dose). I held a day and took 1/2 and was at 2.4 3 days later. I would have been fine just holding one night and resuming at my new dose (which was 70/week).

I've had INR's as high as 7.6 with no bleeding issues. I even took a good spill on a cement sidewalk and didn't get a larger than normal bruise. Since he's already held a dose - no worries on the bleeding.

 

[Jkm7]

I so hope you get some competent care for managing his INR. Do you think a serious conversation about the way this clinic is managing Andrew's coumadin is in order?

You've had a rough month or so and it seems they just can't get it right.
It seems inappropriate to wait three days to get results.
Maybe your cardiologist can suggest another location for you to use. Your confidence in this clinic seems to be uncertain.

Would it be better if you went back to home testing?
Wishing you the very best. Please let us know how it goes.

 

[cocoalab]

I have todays results and he is at 4. I can live with that. I agreed to 2 mg tonight instead of 1.5 as I felt he would drop like a rock. He generally does okay at 3 mg a day but seems to slowly keep getting a little too high if we don't have a day with a little bit lower dose.

Yes management has been a little crazy lately. Part of the problem this last time was a lost cell phone. There had been a message left for me but I was unable to retrieve it. I am a little uncomfortable with how long he was low. It seems like they worry more when he is high. Perhaps I can explain that to her.

Well hopefully he will stay more stable and we can find a perfect dose. We will retest next Wed. I know it might be a little early but i fear if I do it Friday I won't know the results until Monday.

We plan to return to 3mg each day. Should we do another 2.5 this week?

 

[ALCapshaw2]

I have todays results and he is at 4. I can live with that. I agreed to 2 mg tonight instead of 1.5 as I felt he would drop like a rock. He generally does okay at 3 mg a day but seems to slowly keep getting a little too high if we don't have a day with a little bit lower dose.

Yes management has been a little crazy lately. Part of the problem this last time was a lost cell phone. There had been a message left for me but I was unable to retrieve it. I am a little uncomfortable with how long he was low. It seems like they worry more when he is high. Perhaps I can explain that to her.

Well hopefully he will stay more stable and we can find a perfect dose. We will retest next Wed. I know it might be a little early but i fear if I do it Friday I won't know the results until Monday.

We plan to return to 3mg each day. Should we do another 2.5 this week?

I Do Not understand your apparent reluctance to advise Andrew's CARDIOLOGIST of the INR Roller-Coaster these Nurses have your son riding.

His INR Management System is BROKEN and needs someone who understands how Coumadin works to Take Charge and see that ALL the Players (including You and Andrew) are on the 'same page' and that page is the "right page".

Have YOU and Andrew read AL Lodwick's website www.warfarinfo.com?
Do You and Andred have his "Dosing Guide"?

YOU and Andrew need to Understand Coumadin Management, Testing, and Dosing if you ever expect to get him stabilized. These Nurses clearly don't seem to understand how Coumadin works and are using "Step on the GAS, and STOMP on the Brakes" techniques to try and find the 'happy medium'. That NEVER works!

'AL Capshaw'

 

[witzkeyman]

a higher INR is more dangerous than a lower INR. I've had low INR's and my cardio wasn't that concerned. he gave me a stern message, with a high INR you could bleed in your brain. I had an INR of 4.something and my cardio told me to skip 3 days of taking Coumadin.

 

[catwoman]

Yes management has been a little crazy lately. Part of the problem this last time was a lost cell phone. There had been a message left for me but I was unable to retrieve it. I am a little uncomfortable with how long he was low. It seems like they worry more when he is high. Perhaps I can explain that to her.
Well hopefully he will stay more stable and we can find a perfect dose. We will retest next Wed. I know it might be a little early but i fear if I do it Friday I won't know the results until Monday.

We plan to return to 3mg each day. Should we do another 2.5 this week?

Wendy:
We sure have become dependent on cell phones! I have a Bluetooth, and that little gadget has kept me from losing/forgetting my cell phone. People who don't have a Bluetooth aren't aware that you hear a noise (mine is a DUNK!) when you start to lose contact with the phone and a 2nd one when the connection is severed. Many times I've started to leave without my phone but wearing my Bluetooth and that noise has saved me!

The "2.5 this week" -- do you mean 2.5/daily or what?

Have you asked about/seen a copy of the algorithm chart that your anticoagulation manager uses? Last fall, I got a copy of the one my PCP's practice uses. This was when John was on warfarin after his MV repair. I disagreed with how another PCP in our doctor's practice was wanting to adjust John's dosage per his INR results. When I gave our own doctor's nurse my reasons for a different adjustment, she concurred with me.
My own PCP understands warfarin management better than the others in the same practice. But -- downside -- they only do INR tests on Wednesday afternoon, when Dr. Murphy is off.
If I had to rely on a clinic for my INR tests and warfarin management, I would be interviewing several, asking qualifications of who makes the decisions on dosage changes (just a medical degree? any continuing education in anticoagulation management?) and the algorithm chart they use.

If you tell Andrew's doctor that it's easier to replace blood cells than brain cells, he/she just might understand. Just don't let him/her follow that brief statement with a "But..."

BTW, is Andrew a family name? My dad's middle name is Andrew. His dad's first name was Andrew, as was his grandfather's. I've always liked that name!

 

[catwoman]

a higher INR is more dangerous than a lower INR. I've had low INR's and my cardio wasn't that concerned. he gave me a stern message, with a high INR you could bleed in your brain. I had an INR of 4.something and my cardio told me to skip 3 days of taking Coumadin.

And did you do what he said -- skip 3 days? (shudder!)

A low INR can be just as dangerous as a high INR. Of course, that depends on what LOW and HIGH are.

 

[ALCapshaw2]

a higher INR is more dangerous than a lower INR. I've had low INR's and my cardio wasn't that concerned. he gave me a stern message, with a high INR you could bleed in your brain. I had an INR of 4.something and my cardio told me to skip 3 days of taking Coumadin.

Witzkeyman -

The POLITE answer to your post is that your Cardiologist is WAY OUT OF DATE in his advice and needs to Read the CHEST GUIDELINES or attend an Anticoagulation Education Seminar.

HOLDING Coumadin for 3 DAYS for an INR of 4.0 is (insanely) DANGEROUS and FOOLISH. A 3 Day Hold just about GUARANTEES that the patient's INR will CRASH to 1.0 which means that s/he will have NO PROTECTION from Clot Formation. A more appropriate recommendation for your 4.x INR would have been to cut your dose in HALF for ONE DAY and re-test in 4 days.

Hidden within the 14 page memo from Medicare outlining their reasoning in approving Home Testing for Coumadin patients is a paragraph that states that the bleeding risk for an INR of 4.0 is 2X the risk for an INR below 3.0 (and the bleeding risk for an INR of 6.0 is 7X the risk for an INR below 3.0). They also (CORRECTLY) note that the RISK of STROKE rises RAPIDLY for an INR Below 2.0.

By the Way, many patients at High Risk for STROKE are advised to maintain their INR between 3.0 and 4.0. They would probably be DEAD or in a Nursing Home from a Debilitating STROKE if they were under the "CARE?" of your Cardiologist.

This information is WELL PUBLICIZED in the CHEST Guidelines used by Physicians for INR Management. The INR based method of Coumadin Management was developed in the early 1990's and is a MAJOR improvement over the older measurement of Prothombin (clotting) Time prevously used due to variations in the reagents used in making those measurements.

From your repetion of your Cardiologist's Ridiculous Recommendation, I *assume* that you have not read AL Lodwick's educational website www.warfarinfo.com which spells out how to live with and on Coumadin / Warfarin anticoagulation and dispells the Myths of Olde such as the one your Cardiologist still believes.

'AL Capshaw'

 

[Ross]

a higher INR is more dangerous than a lower INR. I've had low INR's and my cardio wasn't that concerned. he gave me a stern message, with a high INR you could bleed in your brain. I had an INR of 4.something and my cardio told me to skip 3 days of taking Coumadin.

You can replace blood cells if you bleed, you can't replace brain cells if you stroke out. Skip 3 days? Why doesn't he just tell you not to bother taking any at all?

 

[perrypiratesdad]

I have todays results and he is at 4.

How can you go from a 6.1 to a 4.0 in 12 hours? There is something else going on it appears. Again, with the half life of warfarin at 2.5 days, I just don't buy those results in 12 hours unless there is something else (large Vit K dose, excessive alcoholic consumption, bad lab results, etc).

 

[witzkeyman]

yes, I did what he said. it was also explained by my cardio that the blood does not cause a clot because of a low INR for a week or so. it's over the course over a much longer period of time.

 

[Ross]

yes, I did what he said. it was also explained by my cardio that the blood does not cause a clot because of a low INR for a week or so. it's over the course over a much longer period of time.

You better run from that person. They are going to get you killed. It only takes a few short minutes for a clot to form. The longer your off, the higher the risk goes. Why do you think people who are taken off Coumadin for a dental procedure have reportedly had strokes right in the chair?

 

[Bina]

a higher INR is more dangerous than a lower INR. I've had low INR's and my cardio wasn't that concerned. he gave me a stern message, with a high INR you could bleed in your brain. I had an INR of 4.something and my cardio told me to skip 3 days of taking Coumadin.

yes, I did what he said. it was also explained by my cardio that the blood does not cause a clot because of a low INR for a week or so. it's over the course over a much longer period of time.

IMHO these 2 statements are completely misleading and no better than a game of Russian Roulette.
I'm very concerned......

 

[Bridgette]

Last year I had an INR reading of 6.1, so I went to the ED but mainly because that same day my son had slammed the car door on my head (by accident, lol) and I was freaking out a bit about that.
But the doctor wasn't really worried at all - he just told me what to look out for in terms of symptoms in case it was bleeding internally a little. He said "you should be fine though" and then he showed me a site on his computer about Warfarin adjustment protocol and discussed what to do in order to get my INR down. The site he was looking on wasn't Al Lodwicks, but the info, from what I could see, was very similar.
Anyway, after that I bought Al's dosing chart which has been a great help whenever my INR is elevated.

And, a few months ago when I went for my check up with my new cardio, I told him that I had tested my INR the previous day and it was 2.0. He wasn't very happy with that and stressed that any reading below 2.0 (for me) warrants a prompt trip to ED to get Clexane injection....he was way more concerned about low INR readings than ones which are a wee bit high.

So I'm happy that my doctors know what they're doing. Gosh Witzkeyman, I think you need to maybe look around for a new doctor, or at least buy Al's chart if you home test (or even buy it anyway).

Good luck
Bridgette

 

[cocoalab]

And did you do what he said -- skip 3 days? (shudder!)

A low INR can be just as dangerous as a high INR. Of course, that depends on what LOW and HIGH are.

No I wasn't told to skip three days. She suggested skipping a second day but I told her that he would just keep dropping. We agreed to 2mg that night. continuing at 3mg the rest of the week until his next test. Sorry for the confusion.

Hopefully the tests were accurate. He has had a history of rapid drops and unexplained jumps. He has many meds he takes and also was on amiodarone for a while. He has been off of that for several months so i hope it is out of his system. He ran out of a pain med for a few days which may or may not have affected this last test. When I home tested and the tests varied like this they blamed the machine. Makes me wonder if it was fine and his results were accurate. Anyways i miss the couple years we didn't have to mess with this drug. We have been on coumadin for over ten years all together. It is okay, just a pain sometimes.