Another dosing consult, please

[AgilityDog]

I will call my cardio's nurse once the office opens.
Surgery 14 days ago. In hospital I was theraputic on 3 mg/day 21 mg/week, but the discharging NP told me to hold that night and restart at 1 mg/day.
Being ill and subject to my husband's fear of post surgical bleeding, I complied with directions, although I argued like crazy about holding or reducing when I was theraputic.

That was Tuesday. By Friday my INR was 1.8. My activity is increasing and I went from not eating to eating normally, including veggies and real olive oil (vit.k). I'm walking around the house and doing 10 minutes on the treadmill daily. I'd hoped to increase that in a day or two.

I'm on Lovenox, of course.

Increased dosage back to 21mg/wk but by Monday INR was only 1.9. Still on Lovenox. In consult with cardio's nurse, online dosing calculator, and algorithm chart, I increased dosage to 24 mg/week, i.e. 3 mg every day, but 4 mg MWF. Of course, I had 4 mg on Monday, and Wed., last night.

Today my INR is only 1.8. Crap. No improvement. And no, there's no change in the test strips.

Prior to surgery, my dosage ran anywhere from 23 to 27 mg/week. I was less active recently, and of course my circulation wasn't that great. I'd say my metabolism has improved considerably since surgery.

So, my question is, do I increase another 15% to 26mg/week, or stay at 24 mg for another 3 days? (since only Monday's dose has really gotten into my system)
What sayeth thou?

 

[ShezaGirlie]

Prior to surgery, my dosage ran anywhere from 23 to 27 mg/week. I was less active recently, and of course my circulation wasn't that great. I'd say my metabolism has improved considerably since surgery.

So, my question is, do I increase another 15% to 26mg/week, or stay at 24 mg for another 3 days? (since only Monday's dose has really gotten into my system)
What sayeth thou?

In my almost 11 years on warfarin, I've found that the more you try to adjust the harder it becomes to get stable. So, since you were on 23 to 27mg weekly and are a little more active now, I'd take 4mg daily for a week and see what your INR is in a week. Goodluck..!!

 

[ALCapshaw2]

How many more Lovenox Injectors do you have?
If you have enough for another 3 days, I'd be inclined to wait 3 or 4 more days, test again, and make your Dosing Decision then, after your body has had enough time to react to your last dosing change. As you probably know, it is not a good idea to make a dosing change before your last change has fully metabolized and stabilized.

Do you have both 3 and 4 mg tablets?
If so, then it is easy to make adjustments in 1 mg steps from 21 to 28 mg/week simply by varying the daily dose
(and taking only ONE tablet per day, thus minimizing cost).

'AL Capshaw'

 

[dick0236]

In my almost 11 years on warfarin, I've found that the more you try to adjust the harder it becomes to get stable. So, since you were on 23 to 27mg weekly and are a little more active now, I'd take 4mg daily for a week and see what your INR is in a week. Goodluck..!!

I agree. Your signature indicates that you have been on warfarin since 2006 and had been stable at 23-27mg/wk....so I would think that your normal range is somewhere around that dose, although since your activity has increased, it may well be, a little higher. Like Janie says, this stuff is hard to "mico-manage".

 

[AgilityDog]

I have plenty of lovenox, with refills. I'm just impatient, I guess. Probably best to hang at 24 another 3 days, then increase to 26 starting Sunday night if I'm not in range yet, test again Wednesday to see if I'm coming up. 10% adjustments rather than 20%
I don't want to overshoot, I just worry more about lovenox than coumadin!

 

[COLLEEN S]

Take additional dose and increase weekly dose by 20%. This came directly off my logarithm chart.

 

[ALCapshaw2]

HELLO !

I'm sorry, but I DISAGREE with everyone who is suggesting a 20% increase based on an INR test with only 2 Doses since your Last Increase. Be Patient, wait until your INR stabilizes from the Last Increase, THEN Test Again and make a decision based on a (hopefully) STABLE result. (That's my NON-profession OPINION and what I would do if in the same situation).

'AL Capshaw'

 

[AgilityDog]

The nurse votes to increase to 26 mg/week, (i.e. increase tonight to 4, tomorrow already set for 4, 3 on Saturday) retest Sunday, or Monday. That's a 1 mg increase tonight, no further changes until Sunday. I'm not staying the same, I've actually dropped a bit since Monday, 19. to 1.8

That's 4 mg every day except Tuesday and Saturday.

If I haven't come up any, then we'll discuss 28 mg for the week on Monday.

She thinks I may wind up on even higher dosage as I continue to heal. And I am to continue eating my regular diet, which includes cabbage, brussels sprouts, spinach, kale, etc. Dose the diet.

Thanks for the input, guys.

 

[dick0236]

She thinks I may wind up on even higher dosage as I continue to heal. And I am to continue eating my regular diet, which includes cabbage, brussels sprouts, spinach, kale, etc. Dose the diet.
.

Your nurse seems to have a good handle on your dosing. Your diet is a lot like mine except for the brussels sprouts(ugh). I do use the vit K vegs to "tweak" my INR. I had a 3.5 INR this AM and fixed broccoli(my nite to cook) for dinner to nudge my INR down a bit.

 

[Cris N]

I agree that the NP is right on the money.

 

[COLLEEN S]

It's ok to disagree. I just wanted to pop back in here and say that the chart did say increase by 10-20%....why they give these WIDE percentage ranges, I'll never know.

 

[AgilityDog]

Well, I'm increasing slowly, up to 2.0 Sunday morning, my usual INR check day. The nurse did suggest it could take another week or two to get me in range as I heal, increase activity, improve circulation, etc.
I'll check in with her tomorrow, and we may change my Tues/Sat 3 mgs to 4 mgs to bring me to 28 mg for the week.

At least the durned INR moved up, rather than down, and I'm not too worried about overshooting at this rate.

 

[ALCapshaw2]

Laurie,

Small Steps are more likely to avoid the dreaded Roller-Coaster Effect.
Adding another 2 mg to your weekly dose and rechecking in 1 week sounds like a good plan to me.

'AL C'

 

[dick0236]

To illustrate how this stuff can change:eek2: quickly.....I ran my normal bi-weekly test in the AM on Thursday, 8/26 and got 3.5. On Saturday, 8/28, I received my replacement Coaguchek from Alere and decided to run a "test" before sending the old meter back. The new meter read 2.5 and the old meter read 2.4:eek2:. In 48 hours my INR readings dropped 1.0:thumbd:. All three tests were make with the same strips, #266. How this could have happened is beyond me, although my wife had been out of town early in the week and I ate TV dinners for a couple days. Since these readings are within range, although at the top and bottom, I am not concerned.....but it is puzzling:confused2:. I am going to check next Thursday just for the helluva it.

And I have not changed dosage in over a year+......I've been on 5mg/day, 35mg/wk.

 

[Bina]

Dick, that really sounds more like the result of a missed dose.....any chance of that?

 

[dick0236]

Dick, that really sounds more like the result of a missed dose.....any chance of that?

I doubt it. I use a 7 day pill box and check when loading the box and again when I take my pills.....however, I never say never.:smile2:

 

[Bina]

Okay then Dick, my second guess would be that while your wife was gone you had a sordid affair with dark, leafy greens.

 

[dick0236]

......... you had a sordid affair with dark, leafy greens.

Bina, I got a hunch that this may be the culprit. I did "heavy up" on greens(wednesday), broccoli(thursday), cabbage(friday). I was trying to pull the 3.5 down a bit....and it looks like I may have overdone it:redface2:.......and then again, I may find a pill on the bathroom floor:frown2:. Either of your "hunches" could have done it:biggrin2:. May be another example of "don't test too frequently":tongue2:.

I really didn't think vit K in dinner portions would have that effect on INR. However, I am one of those "weird" people who only eats one meal per day (dinner)....so who knows ?

 

[Protimenow]

Maybe there was something in those TV dinners that contributed to a drop. Maybe your activity level changed for a few days with your wife gone -- it's been very hot here in Southern California - I don't know where you are, but perhaps some of that drop could be due to underhydration?

When you tested both the new and the old meter, did you use blood from the same incision in both? (I'm asking this because the meter that got the first drop would probably have shown a different reading of you used a second drop in the old one - the XS wants the first drop)

 

[dick0236]

When you tested both the new and the old meter, did you use blood from the same incision in both? (I'm asking this because the meter that got the first drop would probably have shown a different reading of you used a second drop in the old one - the XS wants the first drop)

They were first drops from separate sticks on oposite sides of the same finger.....and those results were surprisingly similar, 2.5 and 2.4. My question is "what pulled the INR down by 1.0 in only 48 hours?". My guess is that it was the "greater than normal" vit K content in my diet, coupled with test variance:rolleyes2:. We'll see what my next test shows. My bet is that it will be 3+.....:smile2: