Bye Bye Amiodarone

[Computec]

Yesterday was my last dose of the feared Amiodarone. During my visit to the cardiologist today I asked when I could come off of it. OHS was 9 weeks ago and I'd heard that patients were on it for a minimum of 3 months.

He did an EKG and consulted my file and said that for a week after my surgery (which included Maze for A-Fib) my heart was in sinus rhythm. Since then the arrhythmia has returned. He did a BP and pulse check and found the BP normal and the PR at 105. He expained that the Amiodarone wasn't working and that he wanted to put me on Toprol instead. I explained to him that I have a tester at home and my PR is usually 60-70 and rarely goes over 90. At this he said there was no need for the Toprol or the Amiodarone.

I know that coming off the Amiodarone will create the need for a higher dosage of Warfarin. My question is will this be sudden or slowly over time as the stuff leeches out of my tissues? I don't have a home tester yet but it's in the works. My wife is asking me to retest the INR through a lab next week. Is that really necessary?

I'm going to keep an eye on my PR and see if the Amiodarone was even partially responsible for the rate staying nice and low. I realize that my monitor won't be much help in seeing arrhythmia but shouldn't that manifest itself as an increased pulse rate? My surgeon said that it would require 6 months to see if the Maze surgery was successful but my cardiologist thinks it was a failure already. Why do they call it "Medical Science"?

Thanks for any advice or shared experiences.

Jerry

 

[Ross]

It will go slowly over time, but not so slow as not notice if you get my drift. I don't think it's necessary to test next week, but I'll let Al Lodwick site the actual timing it takes to see big changes.

Hopefully your heart rate and arrhythmias are over and done with.

 

[Computec]

Al's Da Man

Al's Da Man

Yikes, Ross! I hope my heart rate isn't over and done with! Not after slogging my way over the mountain.

Yes, I had hopes that Al will chime in with some of his expertise regarding this kind of interaction. It should be fairly well documented.

What's the difference between the INR tests for Coumadin and for Heparin? I suspect there are two separate tests because during my original hospital stay, while the medical staff was first establishing my proper level, I was taking the Heparin IV and the daily Coumadin dosage. My understanding is that they watched the INR changing because of the Coumadin while also watching the immediate amount of protection offered by the Heparin. If this was the case then a home tester is designed to watch one kind and not the other. This wouldn't help much if I ever need bridging therapy.

It took 6 days in the hospital to establish an INR of 1.9 at which point they released me and continued to monitor it climb with a weekly lab. Seems like a long time to get it to that level and it's been relatively stable since then.

Another strange thing was that while I was on a course of antibiotics recently a lab was done before and five days after starting them. The INR actually dropped after 5 days of the antibiotics. All of my reading said that it would increase. Diet and exercise were unchanged. Very puzzling.

All the more reason to start home testing.

Thanks
Jerry

 

[Ross]

Certainly await Al's input.

To my knowledge, the only reason they'd be testing your Protime is for the Coumadin levels, Heparin cannot be tested in that respect. As far as I know.

Your slow rise in the hospital--I've found that they give you things to drink that they never realized contained large amounts of Vit K. The kept bringing me Boost and Ensure and a couple cans of it a day. That is a sure way to slow the rise of your INR. I think maybe they did something similar to you? The other factor is the rate at which your recovering. The more active you become, the faster the INR will drop. Sooner or later it's all balanced out. Of course there are still more factors such as discharge meds etc.

Some antibiotics will cause the INR to rise rapidly, not all though. What did they have you on?

 

[ClickerTicker]

Jerry, I was on amiodarone for two years and took my last dose on Feb 22nd. I expected a fairly rapid rise in my warfarin dose, but the reality has been somewhat slower. Difficult to be precise, as prior to that I'd spent a month on vacation in a hot climate which had distorted my INR a bit.
Prior to coming off, my dosage was mostly waivering between 46 and 49mg a week. It's now up to 52.
There's been a recent discussion about how long amiodarone stays in your system. The half-life of the drug is reckoned to be around 50 days, so I guess it's not suprising that the effect on INR is also somewhat slow and prolonged.
What may well be confusing (certainly confuses me) is that an initial heavy loading dose of amiodarone is often given prior to the much lower daily maintenance dose. That loading certainly does mess up your INR big time and real fast (my loading was IV). But once the stuff is in your system, I guess there's no equivalent "unloading" dose so nature has to take its course to get rid of it.
I feel much happier to be off amiodarone - wish it could have happened sooner.

 

[Guest]

It generally takes about 3 half-lives of a drug for the regular dose to build up or wear off in your body. Loading doses are give to shorten the 150 days or so that it might take to get the heart rate under control with loading amiodarone. Since it takes that long to get rid of it, look for your warfarin dose to need upward adjusting upward about Halloween. You should not see much change in your heart rate before then either. I see many people whose doctor took them off amiodarone and they are back on it after 6 months. This is because it really was working (at least a little) and was in their body all that time. When it finally cleared out, it was obvious that it had been working. Your thyroid function may change in 6 months too because of all the iodine that amiodarone was packing.

 

[Computec]

Post Amiodarone

Post Amiodarone

Thanks for the reply, Ross.

The antibiotic I took for 5 days was Doxycycline and my understand is that it would normally make the warfarin more effective. Like I said, my INR went down while taking it. Seemed odd to me.

As for the hospital visit while first starting coumadin, I was started immediately on the Heparin IV and also dosed with coumadin. They tested my INR every 4 hours day and night and were a bit concerned that it was taking so long to get my levels up to where they considered it safe to allow me to go home. In the end it took all of 6 days and they allowed me to leave once I was approaching 2.0. I wasn't eating much while there and there was no Ensure or the like. My appetite was shot.

When I was scheduled for the cardio cath I went off the coumadin 4 days in advance and when the procedure was performed, because of a snafu with the lab, the cardiologist didn't have a current INR reading but performed the procedure anyway since the prep was already completed. After the fact he found out that I was at 1.6 and considered that a bit high for having been off the drug for that long a period. I guess everyone metabolizes the stuff differently and it's a good argument for home testing.

Jerry

 

[Computec]

Life without Amiodarone

Life without Amiodarone

Thanks for the information, Al.

I should have my tester in a week or two and will keep a close eye on the INR as I make lifestyle changes down the road. It's good to know that coming off the amiodarone will cause changes at some future date based on it's half-life. I'll watch for any indication of hyper or hypo thyroid activity as well. Sure hope I don't end up on synthroid because of this.

A question for you, Al. Are there separate tests for monitoring the level of Heparin from that used to measure the INR for warfarin? I know that Heparin is naturally produced in the body. It just seems to make sense that there be a way to measure the effect of the Heparin IV upping that level artificially. It would be great if research could find a way to trigger an individualized, measured increase in the body's production of Heparin to give the protection necessary for each patient. I don't hate rat poison but I'm not in love with it either.

Jerry

 

[Computec]

Time and Amiodarone

Time and Amiodarone

Thank, for your input, ClickerTicker...

You were on it a relatively long time compared to myself. It must have been doing some good or your cardiologist would have had you off of it.

My daily dose was 200 mg and a lot of the literature I've read seems to say that the trouble generally starts with daily doses of 400 mg or greater but some people are more sensitive to it than others. I found the FDA's website to be quite information. I can't remember being given the loading dose following the surgery but then there were tubes and bags everywhere all the time so it doesn't surprise me.

Thinking about the "ClickerTicker" nickname you use. I can't hear my mechanical valve at all. My wife has "super hearing" and she can only hear it when she's directly in front of me in a very quiet room then she can hear it 6 feet away. She can't hear it with her ear to my chest except for the area at the bottom of the sternum. I want to hear it too so I guess I'll be shopping for a stethoscope. I've heard that's a good way to check for arrhythmia too.

Jerry

 

[Guest]

I cannot find that doxycycline ever caused anyone harm. There was a report from the 1970s about something that happened in a lab animal or something and somehow this made its way into Walgreen's computer as something to warn people about. I guess all the other chains decided that if Walgreen's had it then they surely need it in their computer, too. So now it has taken on everlasting cyber-life.

While heparin is an anticoagulant, it affects a less of the clotting mechanism than warfarin. The tests have similar initials but there the similarity ends. It would take millions of dollars and many years to determine a balance between warfarin and heparin. Both are generic so no one company stands to benefit from the knowledge. They have long histories behind them so don't look for govt funding any time soon. Maybe when someone with a mech valve replaces Bill Gates in the $$$ column such a study would get funded.

Computec, I used to work at Queen's.

 

[ClickerTicker]

Thinking about the "ClickerTicker" nickname you use. I can't hear my mechanical valve at all. My wife has "super hearing" and she can only hear it when she's directly in front of me in a very quiet room then she can hear it 6 feet away. She can't hear it with her ear to my chest except for the area at the bottom of the sternum. I want to hear it too so I guess I'll be shopping for a stethoscope. I've heard that's a good way to check for arrhythmia too.

Jerry - my ticking is normally only apparent in very quiet environments. What does seem to happen more often is that the valve causes a sort of "pulsing" (similar to the pipe hammer noise you can get if a cistern valve shuts off suddenly) which is noticeable in my ears when lying in certain positions. I guess that's due to the same conditions as in house plumbing where the flow is suddenly shut off - mechanical heart valves presumably have a much more abrupt shutoff than tissue valves?

 

[Natanni]

Congrats on getting the amiodarone dc'd!!!

Nathan came off of a 3 month post op course of amiodarone in Decemeber, and we didn't notice any sudden, drastic changes; However, we have been told by our vr.com memebers that he will not be entirely free of amiodarone until July 2006 as it leaves the body in a different fashion than many other drugs.

Nathan did go on Toprol, however; I believe it was to control heart rate and also to work in conjunction with his Cozaar, hoping to improve the function of his left ventricle. Congrast again!!

 

[Computec]

I had my surgery at Kuakini with the option of Queens. My surgeon was more comfortable with Kuakini and his comfort was paramount to me.

You should have bought some real estate here, Al. Come to think of it, I should have too.

I don't believe that my valve makes any other sounds, Ticker, aside from the similarity to a barn door slamming shut in a hurricane.

Thanks for the info, Natanni. I'm greatly looking forward to celebrating a 6 month post op and then a six months post Amiodarone anniversary. The further down the road from this whole experience the better everyone seems to enjoy it.

Jerry