A-flutter: Coumadin or not?

[Marge]

Fun at the lab

Fun at the lab

Well, I talked to my PCP last week and I guess I will be doing the coumadin.

Went in for the "baseline test" at the lab on Friday afternoon. Same old same old. Lab tech poked & poked at underside of elbow. Finally got blood out of vein further down arm. "You've got an awful lot of scarring."
Came home with couple of bruises. This is even before I am on coumadin.

I will be testing 2x a week at least for a while. It's gonna be a fun summer.

Thanks for all the input.

 

[Barry]

...Went in for the "baseline test" at the lab on Friday afternoon. Same old same old. Lab tech poked & poked at underside of elbow. Finally got blood out of vein further down arm. "You've got an awful lot of scarring."...

Difficulty getting a vein for a blood draw could be a real pain in the neck - or arm - over time. You may want them to consider drawing from a vein elsewhere - e.g. there are readily accessible veins at your ankles.

 

[Guest]

Testing 2 times a week should almost assure that you will have so many dosage changes that you will never get in range. This is the biggest complaint that I get on my website.

 

[Barry]

Testing 2 times a week should almost assure that you will have so many dosage changes that you will never get in range...

Hadn't thought of that. Doesn't it take 3-4 days for an INR to settle in from a dosage change? If so, yeah, that means that they'd constantly be fussing with the dose whereas if they'd just test once a week they be working from a stable read to adjust doses. Is that the problem with such frequent testing, allodwick?

 

[Guest]

Yes, the dose has not had time to stabilize yet.

The way to get around it is to always look at the dose for the previous 7 days and adjust on that basis. But, doctors who think that testing twice a week is the way to go usually will not do that because they don't understand how warfarin works in the first place.

Very rarely, I have agreed to test someone daily. But they have to be very unstable. That means that they have to come to the clinic even when they are not feeling well.

 

[Granbonny]

Marge

Marge

Will your Lab send your results to your PCP? The same day?I still think it is really bad that your Insurance Company will not approve one for you... Hey, You are a Lawyer.. Fight them I'm wishing that you will get in range soon..and not have to have lab draws but once a month. I know there are many members here..who do not home test..and post..they only go in once a month. ...Hope the same happens soon for you. Bonnie

 

[Barry]

I have another question about coumadin.

I am curious what pain medication you can take when you are on coumadin. For headaches, etc....

I've found that Vicodin works very well and doesn't mess with my INR, and is dirt-cheap in generic form (hyrdrocodone). Downside is that most docs are reluctant to prescribe it as an occasionally-used as-needed med, more likely to prescribe it if you present yourself with a serious owie. Vicodin is an addicting opiate. Thankfully, I'm at no risk of getting strung out on it 'cause it doesn't get me high as it does some people, and I know that if I take it too often I'll build up tolerance and it'll no longer work for the occassional headache.

 

[Marge]

Testing 2 times a week should almost assure that you will have so many dosage changes that you will never get in range. This is the biggest complaint that I get on my website.

Now I am told I only have to test ONCE a week at least for starters. Hurray. Unless something unforeseen occurs or unless I have "changes or factors which may affect my warfarin level," in which case I might be asked to come in sooner.

I tested 2x a week for the first few weeks after I got out of the hospital after the surgery. (This was during those first 3 months after the valve repair.)

I don't recall a lot of dosage changes then. I got fairly quickly up to the range they wanted me in (between 2.0 and 3.0).

My dosage was 5 mg. every night except one day a week when it was 7.5 mg. Apparently that is what they plan to have me take this time around. Does that sound right to you? It got me to 2.5 and pretty much held me there before.

 

[Marge]

I have another question about coumadin.

I am curious what pain medication you can take when you are on coumadin. For headaches, etc....

I've found that Vicodin works very well and doesn't mess with my INR, and is dirt-cheap in generic form (hyrdrocodone). Downside is that most docs are reluctant to prescribe it as an occasionally-used as-needed med, more likely to prescribe it if you present yourself with a serious owie. Vicodin is an addicting opiate. Thankfully, I'm at no risk of getting strung out on it 'cause it doesn't get me high as it does some people, and I know that if I take it too often I'll build up tolerance and it'll no longer work for the occassional headache.

Yesterday I talked to the head of the Kaiser anti-coagulation clinic about pain killers. She said tylenol. I said tylenol has never helped me much. She said, then vicodin. I said: "I have a reluctance to take vicodin for a mere headache! Assuming a doctor will prescribe it! Aren't there some milder, OTC medications I can take?" She says, basically, no. No aspirin based products, and no NSAIDS either.

So iboprofen & its progeny are also a no-no. Is this true?

I am certainly thankful I don't have arthritis.

I just get headaches. I guess I just have to stand them?

She did say there are some (prescription) migraine medications I might be able to take. But I don't have migraines, just very bad headaches from time to time.

 

[Marge]

Difficulty getting a vein for a blood draw could be a real pain in the neck - or arm - over time. You may want them to consider drawing from a vein elsewhere - e.g. there are readily accessible veins at your ankles.

You know, I wondered about that - getting blood from the ankles, I mean.

I even asked about it when I was at the lab on Friday! There was only one tech at the lab (it was late Friday) and she looked startled. I'm not sure she was a very experienced tech. She was very young. When she started poking & prodding, I mentioned, "You guys always seem to have problems with me! Usually they end up calling over one of the old experienced guys!" She drew herself up and said: "I AM experienced! I am VERY GOOD." I didn't want to challenge her further about the ankle draw since she was the only one there. When I go back (I usually go early in the a.m. when they have a full complement of techs), and if we have any repeat difficult draws, I'll ask about the ankle!

 

[Marge]

Will your Lab send your results to your PCP? The same day?I still think it is really bad that your Insurance Company will not approve one for you... Hey, You are a Lawyer.. Fight them I'm wishing that you will get in range soon..and not have to have lab draws but once a month. I know there are many members here..who do not home test..and post..they only go in once a month. ...Hope the same happens soon for you. Bonnie

Bonnie, I don't have a "real" insurance company. I have Kaiser!!!! My PCP, who is a Kaiser employee, will get the results from the lab, which is a Kaiser lab, the same day. (I will also get the results the same day.) If I go in the morning, that is.

My cardiologist, my PCP, the labs where I go for blood draws or any other tests, from X-rays to EKG-echos or CT scans or MRIs, the surgeon who did my valve repair -- they are ALL Kaiser employees or facilities. It is a closed network. I would only get to go outside of it if there was something Kaiser thought I had to have but that Kaiser does not do in-house. For instance, although my surgeon was a Kaiser surgeon, the surgery was actually in a non-Kaiser hospital because Kaiser does not do open heart surgery in its hospitals in my region. (In some regions Kaiser hospitals do open heart surgery.)

I don't think being a lawyer has anything to do with it. My remedy, if there is something I might want that Kaiser doesn't do or cover elsewhere, is to go outside of Kaiser (and pay for it myself) or to give up Kaiser altogether & get a different medical plan. I happen to like Kaiser & am reluctant to switch. I have paid for things Kaiser didn't do, like cardiac rehab. The problem with doing that for the home testing is that Kaiser has to be willing to work with me for me to do it -- which at this point they haven't done. I haven't given up on it yet, however!!!!

 

[catwoman]

Marge:
Does Kaiser not have a Coumadin clinic near you that uses a CoaguChek?

I've used Extra Strength Tylenol since my surgery. Regular Tylenol does nothing for me. At night I take the PM version.

 

[BLENDER]

Coumadin or not

Coumadin or not

Marge
Please think real hard about not taking coumadin. Any risk of stroke is not something to mess with. My mom was not given coumadin and had a massive stroke. It changed her's and our lives like you could not imagine.My mom can't do anything but lay in her bed. She tries to talk to us but we can't undestand any thing she says.Please think real hard before taking a risk of doing somethig that could give you a greater chance of having a stroke.Think not only for yourself, but for your family and loved ones too.I miss my mom, she is here, but she is not.

 

[Marge]

Marge:
Does Kaiser not have a Coumadin clinic near you that uses a CoaguChek?

I've used Extra Strength Tylenol since my surgery. Regular Tylenol does nothing for me. At night I take the PM version.

Short answer to coaguchek/Kaiser question. I've checked, believe me! :-(
Thanks for the tylenol tip!

 

[Marge]

Marge
Please think real hard about not taking coumadin. Any risk of stroke is not something to mess with. My mom was not given coumadin and had a massive stroke. It changed her's and our lives like you could not imagine.My mom can't do anything but lay in her bed. She tries to talk to us but we can't undestand any thing she says.Please think real hard before taking a risk of doing somethig that could give you a greater chance of having a stroke.Think not only for yourself, but for your family and loved ones too.I miss my mom, she is here, but she is not.

Thanks for your concern, BLENDER, I really do appreciate it. I am now starting coumadin so don't worry about me! I am so sorry about your mom.

 

[Barry]

I have another question about coumadin.

I am curious what pain medication you can take when you are on coumadin. For headaches, etc...

After much trial and error and erratic INR's, I finally settled on Vicodin as the pain med I can take with Coumadin. Generic is hydrocodone, and cheap in its generic form. I suspect that all opiates (Vicodin is one) are OK with Coumadin on board. However, note that opiates are addicting and build up tolerance: They're good for episodic pain, but if you take them regularly, especially every day, you'll begin to build up tolerance to where you have to take more to get them to work and eventually you can find yourself getting addicted to them so you have to take them just to keep from going into withdrawal (aches & pain, diarrhea, and flu symptoms without a fever).

 

[Guest]

I have been at a meeting of anticoagulation specialists for the past few days. I talked with Dan Witt. He formerly headed the Kaiser (Denver) Anticoagulation Service but has now moved into a higher administrative position. I told him that I would not quote him but he said that I could use his name. I presented Marge's case. He said that if she were one of their patients, they would fax an order to whatever lab she wanted so that an INR could be done. She would probably be responsible for the lab charges if she did not go to a Kaiser facility (unless she had a real super plan that covers out of Kaiser stuff). When the lab sent the results to Kaiser they would then contact her by cell phone with any instructions. As far as purchasing a finger stick tester this would be her expense. Denver has several people who spend a great deal of time traveling who have purchased these. She could then call her values to the clinic and they would give her instructions. He gave me the impression that the people in her clinic should have known about this and that perhaps she had talked to someone who was inexperienced. If you don't get a good answer, Marge, the ask to talk to s supervisor and even suggest that they call Dan - his phone number will be available to that prerson through their internal phone system.

 

[Wise]

Update:

Just talked to cardio. He explained differences between a-fib and a-flutter. He says difference is basically that a-flutter is "more organized" than a-fib: with a-flutter you have up to 300 electrical impulses from one or two locations in the atrium, whereas with a-fib you have electrical impulses shooting out in a confused sequence from many different locations in the atrium.

He said that when he was in med school (in 80's) it was thought a-flutter was less serious than a-fib, but now after many studies, they think they are equally of concern, and they use basically same treatments. Also, he thinks I could possibly be going from a-flutter to a-fib and back at points not picked up by the Holter because it is only on for 24 hours.

He says my heart rate is quite regular & is well controlled by my beta blocker (coreg). He said he COULD theoretically have me in the hospital for electrical shock to reverse the flutter, followed by anti-arrhythmic medications, but he also says the anti-arrhythmics can be harmful to someone with my heart condition -- more harmful than the flutter itself -- & that anyway I could go right back into a-flutter or a-fib weeks or months after the electrical shock procedure. So it sounds like he does not want to do any of that. He doesn't seem to think there are any long range dangers from the flutter itself. He does not think I am a candidate for electrophysiology (sp?).

So basically it is now back to a decision as to coumadin. He didn't seem to be too concerned if I chose not to take coumadin. He says he has patients in my situation who chose not to (for various reasons) and are doing fine. He seems to be OK with the idea of me being just on aspirin. He said the difference between the risk with coumadin and the risk with just aspirin isn't that huge. I asked him about the cumulative risk over the years, based on the calculations offered me on the board. He doesn't seem to take much stock in the idea of cumulative risk. He said: "It's the same risk -- you have a certain chance of having a stroke this year. You have the same chance next year." And so on through the years. Oh, he did say one other thing: that I am in a different, less potentially disastrous situation just being in a-fib or a-flutter than people who are on Coumadin because of a mechanical valve. If I had a mechanical valve he wouldn't be taking such a laissez-faire approach.

I still have to contact the Kaiser Anti Coagulation Clinic and ask them re: fingerstick and/or home testing -- questions the cardio could not answer.

Just curious Marge as to how you're doing now. I had a cardiac ablation which ended my A-flutter about 15 months ago.

Wise

 

[Marge]

Thank you for the query. I'm fine, as far as I know.

I am supposed to have an echo and see my cardiologist next month and I will ask him again whether there's anything he thinks would be appropriate to do about the a-flutter.

I am curious about the ablation procedure, and when it is considered appropriate to have such a procedure for a-flutter, and when not.

(I am still unaware of when I am in a-flutter even though it was picked up on the Holter.)

Have been doing the coumadin since May with minimal difficulties. Still no home monitoring but the lab is close to me. However, ideally I would like to do something to stop the flutter, rather than just ward of the possibility of clotting and stroke, so I wouldn't have to stay on the coumadin forever.

 

[hensylee]

my brother takes coumadin for a-flutter/a-fib. He's always in a-flutter and sometimes he goes to a-fib and they adjust his medicine (I think it's digoxin - not sure - and maybe another one) - he also takes coumadin for stroke prevention (clots). They did cardioversion on him and it held for awhile, but usually cardioversion doesn't work for very long. They spoke of ablation but never did it.