Cipro antibiotic while on Warfarin

[NorthWoods]

I have a bacterial infection and my doctor is weighing the options of putting me on Cipro, which I used to take with no problem. Has anyone else here been on Cipro while on Warfarin, and how much did you have to adjust the dosing? I know Cipro raises the INR, and is different in everyone, but am curious what the effects are.

 

[Chuck C]

Hi.
I was put on cipro for 6 days while on warfarin. It seemed to have virtually no effect on my INR. Do you home test? I home test and do so about once per week. One of the many nice things about home testing is that if I go on a new med, I can test as frequently as I like to check for any changes in my INR. Having read that Cipro can increase INR, I decided to test frequently while on my 6 day course of cipro.

I am not suggesting that one needs to test as frequently as I did, but I like data, so I tested my INR most days while on cipro.

At the time my INR target range was 2.5-3.5 and I kept my normal warfarin dosing:
INR
Day 1: 2.9
Day 2: 2.4 interesting
Day 3: 2.7
Day 4: 3.0
Day 6: 2.9

So, at the end of the week my INR ended up being exactly the same as at the start, with no increase in my INR.

I found this study interesting; two arms, 500mg cipro arm and placebo for 10 days.

" No patient experienced a significant increase in INR. No patient experienced a bleeding event. These data support the fact that a warfarin-ciprofloxacin interaction does not routinely occur at this dosage and duration of ciprofloxacin therapy. "

https://pubmed.ncbi.nlm.nih.gov/1492006/
So, this study had the same outcome of my own personal n=1 study with myself.
There have been case studies which have observed increases in INR when individuals were put on cipro, so individuals may vary and it is best to test your INR after a couple of days on Cipro to see if it is having any effect.

If you don't home test, you can have your physician send the lab a few standing INR test orders so that you can check INR from time to time, to see if you get any INR movement, and then dose your warfarin accordingly.

 

[NorthWoods]

Thank you for the info Chuck! Very helpful. I do home test every two weeks. I have the On-X valve so my target INR is 1.5-2.0. It has been very stable between 1.6-1.8 for months now and I honestly really don't watch what I eat or drink. I still take 81mg aspirin daily, mostly Tylenol for back pain or headaches, and sometimes mix-in Advil with no effect on my INR.

Shawn

 

[Warrick]

I was on an antibiotic (miconazole) years ago, its listed as one that ‘may’ affect INR.
My INR ended up getting to 7.7 but it took 3-4 days to go up so I would be inclined to advise test test test daily when on it until you know what affect it will have on you personally.

 

[pellicle]

Hi

I'd concur with the others and say that as long as you monitor your INR for changes and make any dose adjustments contingent on INR falling out of range you'll be find.

I do home test every two weeks.

since a new thing has been introduced I suggest you bump that to weekly during this test. Indeed On-X did weekly testing to get their narrow road through and if you drop low the punishment for an extra week of not knowing can be harsh (stroke).

I have the On-X valve so my target INR is 1.5-2.0. It has been very stable between 1.6-1.8 for months now

that's fortunate and convenient, but plain sailing is of course easier than sailing into headwinds, if your experience is only "managing plain sailing" then any turbulence or changes may require learning a few new skills. That's not a bad thing and helps you feel even more confident in managing your INR as time goes by

I'd start by considering adjusting your INR up a little to give you room to react. Imagine doing 100kmh on a freeway then doing the same down a narrow alley, with the walls so close any deviations suddenly seem more serious.

and I honestly really don't watch what I eat or drink. I still take 81mg aspirin daily, mostly Tylenol for back pain or headaches, and sometimes mix-in Advil with no effect on my INR.

that's all good and pretty much your reactions to advil is normal.

Shawn

suddenly reminded of a movie I like

anyway, reach out if you encounter any headwinds you have questions about. I think you'll be fine though

Best Wishes

 

[NorthWoods]

I called my INR supply company and ordered some more test strips. I am going to monitor every 2-3 days and see what the results will be, and document of course. That way if I have to go back on the Cipro again down the road, I'll know what the results will be like.
I'm on 24mg a week of Warfarin, so quite possibly little or almost no adjustment will be needed, but we will find out in a couple of days. I was already scheduled to test this Friday, but will do it a day earlier. I am seeing maybe more greens in my coming days!! I've been craving a big Cesar salad so this might work out well.

 

[Chuck C]

I am seeing maybe more greens in my coming days!! I've been craving a big Cesar salad so this might work out well.

That's good. Greens are very heart healthy. I eat at least one and sometimes two large Mediterranean salads per day. It is totally ok to eat greens while on warfarin, as long as you are regularly checking your INR. My INR seems to be almost totally unmoved by the amount of greens that I consume, and most others here will tell you the same thing- but if it does move for you, just adjust warfarin a little.

 

[pellicle]

Hey

I called my INR supply company and ordered some more test strips. I am going to monitor every 2-3 days

I've found that less than 3 is only useful for accurate data checking. Resist any temptation to adjust dose in less than 3 days unless you are seeing a clear trend up (or down).

and see what the results will be, and document of course.

☀

I'm on 24mg a week of Warfarin

so how is this administered? Because 24mg a week is a weird way of thinking about a dose that has a half life (you know, goes away over time). I know its popular here on VR (well, to me "there" in primarily American Land) but to me it brings nothing to the table that your daily dose would not bring and obscures thing (like your administration regime).

The body doesn't know about weeks, or months, or even years ... they're human creations (and probably the humans who didn't really get it with respect to proper warfarin management). Beware of big alternations or staggering / stacking of doses

So, lets look at what may likely be the resulting levels of warfarin in you after you follow a dose pattern like:
3.5 daily vs 2's with alternating 5's

I didn't bother with a trend line for the consitent one ... you can see its flat.

So if your goal is a consistent INR then it seems reasonable that a really good start is a consistent daily dose.

Of course I'm not a Doctor and just a typical layman. The above views are pretty close to what "typical laymen" usually do, you know, think statistically, consider pharmacokinetics and graph stuff accordingly.

;-)

so quite possibly little or almost no adjustment will be needed, but we will find out in a couple of days.

yep ...

I was already scheduled to test this Friday, but will do it a day earlier. I am seeing maybe more greens in my coming days!! I've been craving a big Cesar salad so this might work out well.

you know, you sholdn't really hold back on that stuff.

Why not conduct and experiment after you've done the cipro. Eat "normally" for a week and then while checking INR every day eat a big Cesar salad and see what happens in the following 3. Then do it again in a few weeks time ... if there is a pattern you know, and also if there is no pattern you know.

 

[NorthWoods]

Sunday-2mg, Monday-4mg, Tuesday-4mg, Wednesday-4mg, Thursday-2mg, Friday-4mg, Saturday-4mg
Already took my INR when I got home from work. 1.5
After dinner tonight, I take my first dose of the Cipro. Will test again Thursday morning.

 

[Chuck C]

Sunday-2mg, Monday-4mg, Tuesday-4mg, Wednesday-4mg, Thursday-2mg, Friday-4mg, Saturday-4mg

Something to consider. I'm not suggesting that you change things right now, as you just went on Cipro. But, you maintain an INR of 1.5-2.0. That does not leave much safety margin and they have you dropping your dose by 50% two days per week, from 4mg to 2mg.

As you just experienced, you are now at INR 1.5. - No margin for your zone of safety.

The dosing above represents 24mg/week. So, why not take 3.5mg per day, which would be about the same average dose? You could take a 3mg and half of a 1mg. That way you are taking the same dosage every day and less likely to get swings in INR. Anyway, something you might talk to your cardiologist about on your next visit. With targeting 1.5-2.0 INR, the last thing you can afford is swings in INR.

 

[NorthWoods]

I have thought about that. I'll run it by my primary Dr when I go-in for my yearly physical. I don't have my first echo follow-up till April. Will be awesome to see the new valve!

 

[pellicle]

Sunday-2mg, Monday-4mg, Tuesday-4mg, Wednesday-4mg, Thursday-2mg, Friday-4mg, Saturday-4mg
Already took my INR when I got home from work. 1.5
After dinner tonight, I take my first dose of the Cipro. Will test again Thursday morning.

Do you only have 4mg pills?

Also, it soon gets pretty confusing when you say tonight and then a named day. Not only because I'm already in Wednesday here in Australia, but in a few days time someone reading this so have to pull up a calendar, compare date posted and work it all out.

Also seriously consider getting some smaller doses, for instance I have 1, 3 and 5mg tabs to make dose adjustments easy. While some people seem to get excited about requiring a small dose, it's actually a PITA to tune in.
I call those variations problematic and as extreme as my example.

Personally I'd love to see a week or two of every second day readings. It would sure clear up if my theory is wrong or not

 

[pellicle]

The dosing above represents 24mg/week. So, why not take 3.5mg per day,

Probably because of pill sizes.

And besides 3.5mg a day sounds too simple... You haven't got anything else to work out.

 

[slipkid]

Also seriously consider getting some smaller doses, for instance I have 1, 3 and 5mg tabs to make dose adjustments easy.

I do the same thing - have 5, 2, & 1mg on hand. Currently am taking 7mg 4 days alternating with 6 mg in between on 3 days per week. I've been pretty stable where I want to be (low 2's) although sometimes I make minor 1mg adjustments if multiple tests look too far one or the other way..

I find the biggest pain with getting the assorted dosages is the horrible computerized drugstore system here used at CVS - I am required to use CVS by my insurance. The computer does not understand that I am on different doses of the SAME drug. Refills constantly get effed up and worse when my Dr writes out a prescription say for 60 pills good for a year with multiple refills allowed it gets processed with weird shtt like no refills allowed or refills that expire earlier than when I use up the drug (system thinks I a taking that pill 7 days a week which is not the case for any other than the 5mg pill), Happens to me constantly, plus despite my declining autorefills they do it anyway when I am not even ready for a refill causing other hassles (I try to call in for a refill with 1 left but the automated system tells that my order # does NOT EXIST; leaving me scratching my head and having to go there in person or try to speak to a tech over the phone, only to learn that the system refilled itself automatically leaving 0 refills then contacted the Dr and got a new prescription so the order # on my pill bottle at home with 1 refill left actually is completely deleted and replaced with a new one, all without my knowledge).

Worse is the crap that CVS' mail order system called Caremark uses which I have told the Dr and CVS I do NOT want to use, who in the past have even autorefilled drugs I was no longer even on and been a major pain to try to return.

 

[pellicle]

I find the biggest pain with getting the assorted dosages is the horrible computerized drugstore system here used at CVS

sometimes I'm happy to live in an isolated semi 3rd world colony

 

[Warrick]

You aussies still ride round in roo’s don’t ya?

 

[pellicle]

You aussies still ride round in roo’s don’t ya?View attachment 888283

Sure, only way to clear the traffic jams

 

[Chuck C]

I find the biggest pain with getting the assorted dosages is the horrible computerized drugstore system here used at CVS - I am required to use CVS by my insurance. The computer does not understand that I am on different doses of the SAME drug.

I have had the exact same problem. Got my 6mg filled, but the as to the accompanying 1mg dose:

"There is a problem with the prescription and the pharmacist needs to call your doctor."

Me: "Perhaps I could help. What is the question- seems the prescription is pretty straight forward."

Costco pharm: "Sorry, he needs to talk to your doctor. "

Well, rather than call my cardiologist, who wrote the prescription, and would have sorted them out, they called the Coumadin Clinic doctor who has not overseen my dosage, nor communicated with me in over 4 months.

It takes them 2 weeks to sort it out and boy did they sort it out. I get a text indicating that my 4mg warfarin is ready. 4mg???

So, the pharmacist, guided by his computer, got confused as to why I would need 1mg pills, when the dosage from an old Coumadin Clinic prescription says "Take 4mg per day." Never mind that I now take 6 to 6.5mg per day, as my dosage increased during my first several months of taking warfarin, as happens with most. So, being super knowledgeable about such things, the Coumadin Clinic, not having any data or communication from me in 4 months, instructed them to change my 1mg prescription to 4mg. Good thing that they just didn't as the patient, because only "doctors" know answers to these complex questions.

When you get the Coumadin Clinic and the pharmacist communicating with each other to sort things out, it can sometimes be like these two trying to figure out your correct dosage and prescription:

 

[Keithl]

I have had the exact same problem. Got my 6mg filled, but the as to the accompanying 1mg dose:

"There is a problem with the prescription and the pharmacist needs to call your doctor."

Me: "Perhaps I could help. What is the question- seems the prescription is pretty straight forward."

Costco pharm: "Sorry, he needs to talk to your doctor. "

Well, rather than call my cardiologist, who wrote the prescription, and would have sorted them out, they called the Coumadin Clinic doctor who has not overseen my dosage, nor communicated with me in over 4 months.

It takes them 2 weeks to sort it out and boy did they sort it out. I get a text indicating that my 4mg warfarin is ready. 4mg???

So, the pharmacist, guided by his computer, got confused as to why I would need 1mg pills, when the dosage from an old Coumadin Clinic prescription says "Take 4mg per day." Never mind that I now take 6 to 6.5mg per day, as my dosage increased during my first several months of taking warfarin, as happens with most. So, being super knowledgeable about such things, the Coumadin Clinic, not having any data or communication from me in 4 months, instructed them to change my 1mg prescription to 4mg. Good thing that they just didn't as the patient, because only "doctors" know answers to these complex questions.

When you get the Coumadin Clinic and the pharmacist communicating with each other to sort things out, it can sometimes be like these two trying to figure out your correct dosage and prescription:

One of the greatest comedy routines of all time, love it every time I see it!