Any advice welcomed please

[sheridan07]

I had my INR done today and it was 2.2. I have a St Jude's mechanical valve that replaced my aortic valve. My range like most others is 2.5- 3.5. I was told that I would have to take two 120 mg Lovenox shots today along with doubling my dose of warfarin. I normally take 6 mg but tonight have to take 12 mg. I questioned the nurse and the doctor about this and they said they " are being proactive". My cardiologist has left the practice which left me with this new doctor. My concern is that this is alittle extreme on the doctors part to get my level back above 2.5. I had been lower with my other doctor and never been on lovenox. I'm I worring for nothing or should I look at other options? Thanks for your help. Brian

 

[nngbwh]

I have a St.Jude Mechanical valve and know the doc are satisfy with 2.0 - 3.0 range. Anything under 2.0 i will need a Lovenox shot.

 

[sheridan07]

I was told anything under 1.9 with an aortic mech. valve than I would but I'm 2.2. I don't want to go in tomorrow and be 4.0 or higher. I haven't been off on my inr in a while and it seems they panic when it does.

 

[Protimenow]

I'm not very familiar with the action of Lovenox, so I won't comment on that.

However, if you're taking 6 mg/day and at 2.2, I'd be concerned that doubling your dosage would get you a ticket for a front row seat on the INR roller coaster. It just may knock your INR to 4.0 or higher, then you'll be decreasing dosage, and shooting for your target range, and then adjusting many times until you're where your doctors want you to be. It sounds like whoever advised this change is being a bit more than proactive. (Is this doubled dose just one time, or do they want you to do double it every day? A one time increase from 42/week to 48/week is a bit more than 10%, but might not be considered extremely drastic. I think it probably makes sense to do a 10% increase over a week - so you perhaps take 6 mg five times a week and 7.5 mg the other two days (Tuesday and Friday?), or something like that, which wouldn't cause your INR to bounce around).

Going in tomorrow, after taking 12 tonight probably wouldn't show any difference that can be credited to the increase in warfarin dosage. It sounds like your doctors have to be able to differentiate between the effects of Lovenox and those of Warfarin and to take into account the longer half life of warfarin's effects.

I have an aortic valve and I'm not especially concerned when my INR is 2.2 - nor were my doctors.

 

[dick0236]

I checked two INR protocals for adjustment for 2.2 when range is 2.5-3.5:
1. Al Ludwick (I use this one as a guide)- increase weekly dose 10-15% and check in one week.
2. On line calculator, Pace-Med-Apps.com - increase weekly dose 5-10% and check in 7-14 days.

Neither says anything about using Lovenox. In 43 years of using warfarin, I have never had an INR that required Lovenox, and I personally would not use Lovenox for a 2.2.

Personally, I would increase by 1/2 regular daily dose (one time only) and check in a week.:smile2:

 

[Eva]

Brian, do you test at home?

Protimenow and dick are correct. I do not think you need the shots. 2.2 is not too low and I won't be worried about it.

Normally I do not give advice here, but since I have been self-dosing for the last 18 months and have been doing well, and if this was me:


I would take 7 mg tonight (if worried), 7 mgs tomorrow, 7 mgs after tomorrow and continue with 6 mg. I would retest in a week.

Normally the increase is usually between 5-15% depending on were you are and where you want to be. In your case, I would increase it by 6% only.

 

[tommy]

Geez, I sure don't like countering the doctors orders, but this sure seems extreme to me. I know we are all different, so I'm not trying to trash your doctor from afar, but I'd dig in again, and consider getting a second opinion. PS, you might inquire about the 2.5-3.5 target range too. Mine used to be 2.5-3.5 and was changed a few years ago to 2.0-3.0. I have a St Judes mechanical.

 

[ALCapshaw2]

The *usual* INR recommendation for an Aortic Valve Replacement with NO other risk factors is 2.0 to 3.0.
I use AL Lodwick's Dosing Guide (as shown by dick0234) and tend to limit my dose changes to the low end of his recommended range. Works for me. If you are taking 6 mg every day, that comes to 42 mg/ week. If you only have 6 mg tablets, I would be tempted to take an extra 3 mg tonight and check in 1 week (same as Dick's recommendation). That will raise your INR slightly, hopefully enough to reach 2.5, but if not you can make another small increase next week.

Prescribing Lovenox for a 2.2 INR seems like an Over-Reaction to me.

Telling you to Double your Dose for 2 days sounds like Gross Incompetence to my mind.
"Loading Doses" have been found to lead to the Roller Coaster Effect and are NO LONGER Recommended by most competent (and up to date) managers.

It would help to know your weekly dosing schedule to make a more detailed recommendation.
If your weekly dose is less than 42 mg, you could get some 5 mg tablets in addition to your 6 mg tablets
and then adjust your weekly dose anywhere from 35 to 42 mg simply by how you allocate the 5 and 6 mg tablets as needed, taking only 1 tablet per day.
5.5.5.5.5.5.5 = 35 mg/week
5.5.5.6.5.5.5 = 36
5.6.5.5.5.6.5 = 37
------------ etc.
6.6.6.6.6.6.6 = 42 mg/week

'AL Capshaw'

 

[sheridan07]

Thank you all so much for your advice. I'm not worried at all over my 2.2 level. I am worried like everyone has said about the roller coaster affect the shots and the double dose will play. My dosing gose (or should I say went as) 6 mg 7 days a week. My doctor who just left the practice wouldn't have stood for this. He has told me in the past that he would only give me lovenox if I was under 1.9 for 2 inr visits in a row, which I think would be two weeks. I will be looking for other options for my inr checks. How do I go about getting my own testing machine? Thank you all for your help. It means a lot that people care.

 

[Protimenow]

Brian:

I see that you've gotten some good advice here (even some advice from me). Self-testing is a good way to go, and it seems like you'll be able to make minor adjustments, if necessary, and to manage your own INR (at least, you've come to a great place to get good advice).

Regarding getting a test meter, there are many ways you can go. In other postings, I've seen that the forum can't recommend going to any other than an authorized source of the meters. If you have insurance, and can get the insurance companies to pay for the meter and/or the strips, this is probably the best way to go about it. You can check with your insurance company and see what their policy for meters and self testing are.

There are also companies like Alere and Philips that provide the machines and supplies and notify your practitioner when you tell them the results of your tests. These companies are experienced in working with the insurance carriers, and may help you to get started with self-testing.

I'm sure others on this thread will probably have better advice on dealing with insurance companies and companies that are able to help with coverage than what I'm giving here.

In my case - and I am only speaking about my own case and am not suggesting that you do what I've done - I had no insurance; I am not old enough for Medicare, and I had few options. I couldn't afford a new meter, but I desperately wanted to do my own regular testing and anticoagulation management. I went to eBay for my meter. I've noticed that, over the past year or so, prices for ProTime meters, especially, have dropped very dramatically. I have a few ProTime meters (although I really only need one), and, once I got over the learning curve, I've been able to successfully test almost every time. You'll find the ProTime meters on eBay for around $60-80, and you may even be able to make an offer to the seller and get one for even less money. My experience with the ProTime has been good, in part, because the strips have quality controls built into the strips. I've verified my results with a lab and the results have been in very close agreement. As far as strips - I had a doctor friend order them from a medical supply company - this saved me probably $50 or so for 25 strips. I also have a CoaguChek S that I bought because I wanted to see why people on the forum prefer CoaguChek and InRatio over the ProTime. I would steer away from the CoaguChek S because Roche will stop supporting it - and stop selling the strips - by October of next year. If you are in the situation I was in when I bought my meter(s), a meter on eBay is an option to consider. Again - I'm not trying to tell you what to do - I'm merely answering your question.

If your insurance company will partially (or totally) pay for a meter and/or the supplies; or if you find a vendor who can work with your insurance company and get the meter and supplies; this is probably preferable to the route that I took.

My strong belief is that anyone who is taking an anticoagulant should be able to be tested, and properly managed, regardless of insurance or their ability to pay. For some, getting an accurate meter affordably may be the only option until clinics that provide these services on an ability to pay basis become more available.

 

[sheridan07]

Thanks so much protimenow, you are very helpful. I will be looking into self testing. I have been reading a lot of great threads on this site on this matter. If they panic over a 2.2 reading, then I hate to see what they would do over a 1.7 reading.Thanks again for your help

 

[Herb M]

Both the recommendations pertaining tp lovenox and doubling your doseage are very bad recommendationds.

There is no need for lovenox and probably no need to adjust your doseage. You could add a half of tablet for one day and see where that takes you.

The recomendations you recieved from you doctor are so bad, I would consider changing the doctor.

 

[Protimenow]

Brian:

I'm glad I could help. I hope that others who have navigated the Insurance maze will provide you with better information about Insurances than I have.

 

[danlo5o]

Ditto to Herb M's post. The advice you received to double your dose and take two Lovenox shots is really quite frightening especially given that your INR was 2.2 which is within the recommended range. I think your INR would be in the 5-6 range if you did as you were told.

I was at 1.9 taking 2mg - 4 days a week and 3mg - 3 days (17mg/week). They wanted to get me up in the 2.5 range so they increased my dose to 3mg - 7 days a week for a total of 21mg per week. My INR has been 2.4 and 2.5 the last two weeks. It doesn't take much of a dosage increase to raise your INR.

Dan

 

[sheridan07]

Herb, I am looking as I speak. My level today was 2.1 ( yesterday 2.2) and I saw a different nurse today who said she couldn't understand why I was on Lovenox and also why I was back today, when I only had 1 night of a dose change. She talked to a different doctor who had the same feelings as she did and recommended me to take 9mg tonight and every friday and take 6 mg on the other six days. The doctor told me to stop taking Lovenox and told me to come back for another Inr check on sept 27th. Thanks again

 

[Jkm7]

Good news, Brian.
Sounds like you found a nurse and doctor who are more coumadin educated.
Hope you reach your desired spot quickly.

 

[sheridan07]

I know Dan. Yesterday was a strange stressful one. I had my ohs 1 1/2 years ago and I walked out of the hospital with an Inr of 1.7 and none of the doctors then put me on Lovenox and within a week later was within the range. I move to another state and another cardio practice and some of the doctors panic over readings at 2.2. Makes me wonder sometimes about things. I am looking into other doctors and I am looking into self testing. Thanks Dan

 

[sheridan07]

Thanks Jkm

 

[ALCapshaw2]

Brian,

You may want to pick up a 30 day supply of 1 mg tablets for making adjustments.
If you are taking generic Warfarin, this would only cost $4 or $5 at major pharmacies (CVS, Walmart, etc.)

For a weekly total of 45 mg, I would follow this schedule:
6.7.6.7.6.7.6 = 45 mg/week

Personally, I prefer to minimize my day-to-day variation vs. taking a larger single dose once per week,
just to make the dosing more 'even'.

'AL Capshaw'

 

[Protimenow]

Brian:

I don't mean to embarrass Al, but I certainly value his advice. The only thing I would suggest is that you can probably get 90 1 mg generics for $10. And hitting 45/week switching between 6 and 7 sounds much better than 9 twice a week and 6 all the other days.

I'm glad to see that you've found a doctor and nurse who really DO seem to know what they're doing. (Don't give up on the idea of getting your own meter, if you feel like doing your own testing and, perhaps, also your management - it's an empowering feeling to be able to actually test your INR, rather than having to go to a clinic or doctor's office where they ALWAYS know more than you do. Also -- it sounds like you got lucky THIS time - next time they do an INR, you may wind up with a new set of fools who know enough about INR management to issue bad advice).