changing coumadin dose

[Beverly]

This message is for Al Lodwick

I had my aortic valve replaced 12 years ago with a St. Jude valve and have been taking coumadin ever since. For a considerable amount of time now my dose has been 7 mg. daily. Recently I got a result of 40.0 with INR of 4.3. My PCP felt that this was high and wanted it repeated in a week. I repeated the test at the lab yesterday and got a call from the Dr.'s office that said only that it ( I presume the INR) was 4.8 and the Dr. wanted me to skip taking the med for two day and then to cut it to 6 mg. daily and repeat in one week. According to things I have read on this site it takes a few days for changes to show up so do you think this is too may changes at once? In the past skipping etc had caused a big drop and I am a little uncomfortable with this instruction. I have lost 111 pounds in the past year and a half but most of that loss took place in the first year and did not affect my coumadin dose. What do you think?

 

[JimL]

Beverly,

At my last blood test, the nurse said to me, "You've never been constant!" I was down to 2.2, and had been steadily dropping for the past couple of weeks. I had cut my dosage from 41 mg per week to 40 mg per week, and dropped .6 each week. I've now increased again to 41.
There must be something else to affect the INR, like increased exercise, diet, or as Nancy says, something about the phase of the moon.
I personally would not want to skip a dosage even for one day -- although I think I've done that too. Do you regulate your own coumadin dosage?

 

[Christina]

Hi Jim and Beverly,

Coumadin interferes with many things and is not an exact science. I also go up and down, some weeks more so than others. I do pretty much my own dosaging but do call the doctor every other week with an INR reading. He tells me than to decrease or increase.
When am high he also will tell me to SKIP Coumadin for 48 hours, but I don't do that. I know my body by now how it will react to that and I know that I will go to the bottom. I just cut my dosage in half for two days and have been fine. I don't tell the doctor this as I want to keep him as my friend. I like him, but he doesn't know my body as I know it, and I just don't feel like arguing.

Wishing you the best.

Christina
AVR 8/2000 Tucson, Medical Center, Tucson. AZ
St. Jude's Mechanical
Dr. Gulshan Sethi

 

[Beverly]

changing coumadin dose

Reply to Jim L.

No I don't regulate my own dose. I have always had to go to the lab and rely on the Dr.'s office to call with instructions. My dose has only changed a very few times in all these years so I think that skipping two days is a bit much.

 

[Guest]

Beverly,

IF YOU WERE MY PATIENT, I would probably have you hold warfarin for only one day. You take a fairly large dose of wrafarin, so your INR will probably drop quickly. Even the "average" patient will drop their INR by about 1/2 with a 48 hour hold. So if the average patient's starting INR was 4.8, the a 2-day hold would be expected to produce an INR of 2.4 -- below your desired range. You will probably drop faster. Reducing the dose from 6 to 7 mg per day is reasonable. I usually do not take any drastic measures if the INR is below 5.0.

If we took a poll of everyone who reads this and has had an INR of 5.0, we would find very few serious complications (bleed into brain or bleed requiring 2 or more units of blood), a few more moderate bleeding episodes (nose, bowel, bladder), more minor nose bleeds, but the vast majority of the time nothing would have happened.

An INR of less than 5 with no bleeding rarely requires more than a 1-day hold to bring it into the desired range.