Coumadin Clinic

[mecretired]

My ins just denied my INR home testing for the 2nd time. They consider it a convenience item and I can't get my doctor interested in trying to convince them it is a medical necessity. He wrote them a very basic letter that wouldn't have convinced me. I have an appt on the 7th--will talk to him then. I also have a BIG problem with my coumadin clinic (as I hear a lot of you do). I didn't agree with some of their dosing instructions and went against their advice (with advice from some of you) so I called to "fess up". She didn't want to hear about when I first went against their instructions or why. She only wanted to know what I was actually currently taking. She thinks weekly testing only results in too many up/down INR's. She actually went off on me when she found out I had 5mg tabs and 2.5mg tabs. She insists that all patients have just 1 strength of tablet--that makes it easier for her to give dosing instructions--I explained that I was intelligent enough to understand mg and could figure it out--she actually hung up on me. She evidently send my cardiologist's nurse a msg about my phone call because the nurse called and left a msg for me telling me about the new drug Dabigatran that I could take instead of Warfarin. Even I know that it has just been approved for AFib not artificial valves!! Let me give you a very brief history of INR/dosage and tell me what you think my current dosage should be.
INR /Coumadin Clinic said/ What I did
8/9/10 2.5 stay at 42.5 mg/wk/ same
8/16/10 1.9 increase to 45/wk/ same
8/25/10 3.1 stay at 45/wk/ same
9/7/10 3.1 stay at 45/wk/ same
9/28/10 2.6 stay at 45/wk/ same
10/20/10 2.5 stay at 45/wk/ same
11/3/10 2.0 increase to 47.5/wk/ I increased to 52.5/wk
11/16/10 2.1 increase to 52.5/wk/ I increased to 57.5/wk
11/29/10 3.4 decrease to 50/wk/ ?
I was on Omnicef for an ear/sinus infection from 11/11-11/21--she said that antibiotic could have been responsible for big change so I should decrease dosage ??
I would really appreciate any advice. I feel I am getting bad info from coumadin clinic, they are not supporting home testing, and I am beginning to get very depressed about all of it. Thanks, Mary

 

[JimL]

I rarely change more than 1 mg per week, and I still have plenty of problems getting the right dose.
My coumadin nurse has a fairly new computer program which calculates for her what the dose should be. BUT -- it only handles one size pill in its dosages! That might be why your clinic insists on only one size pill. I've been stocking 5s and 6s for years. As long as the coumadin clinic lets you know the INR, you'll be fine, you can still take whatever dosage makes sense. You might find it more economical to get 6s instead of the 2.5s, or perhaps even 7.5s.

 

[Protimenow]

Actually, I don't see anything wrong with the dosage recommendations that you were getting from the anticoagulation clinic, and I can understand why they were upset with your taking things into your own hands. The advice they gave appeared to be competent to me (not that I'm an expert). Guidelines usually suggest making changes of no more than 5% of your weekly dose. Also - you've got to consider that they probably have some liability issues to be concerned about -- if something bad happens because of their poor management, this is one thing -- but if it's because you ignored their advice, they may wind up on the hook for something they had no control over.

Many testers seem to be content with testing every two or three (or more) weeks once their INRs are stable. In your case, because you started a new medication, it seemed to make sense to test more frequently - especially since your INRs DID change with the new medication. So -- I may be inclined to go with their recommendation of testing less frequently -- unless I made what could be a considerable lifestyle change -- eating foods with much more (or much less) Vitamin K than usual, switching on or off of a medication that may effect INR, etc. Your clinic should be flexible enough to retest at shorter intervals if you've made some changes that you fear might effect the INR.

As far as dosages -- it's certainly less expensive taking one or two pills to reach the right dosage -- one 10mg tablet costs much less than 10 1 mg tablets. Personally, I have a bottle of 10 mg and a bottle of 4 mg. My usual 7 mg dosage is achieved by taking one half of each pill. If your clinic has a program that only bases doses on one single pill size - that's okay - let them tell you the weekly dose and you can figure out how to spread it out fairly evenly over seven days.

Personally, I greatly appreciate the feeling of empowerment that I get from being able to self-test and self manage. I appreciate the fact that I CAN manage my INR and not have to go for long periods between tests.

HOWEVER - if there was an easily accessible neighborhood clinic that can do the testing at little or no charge to me, using their meters and strips, I wouldn't be opposed to going to THAT clinic for testing and, possibly, management. IF I ever travel, and plan to be away for a long time, having a meter and strips that I can take with me, to be able to keep an eye on my INR, wouldn't hurt, either.

 

[Freddie]

Your INR range is 2.5 - 3.5, yes? Normally there is nothing wrong with a 3.4 result, I wouldn't change a thing. But assuming you are now finished the antibiotic's dropping 2.5mg just might get you in your "sweet spot".

If I'm reading this correctly, your INR dropped while you were on antibiotic's (usually it causes INR readings to go higher).

 

[Cris N]

As far as testing is concerned, have you asked your PCP about it instead of the cardio? My PCP is enthusiastic about home testing.

 

[Country]

mary,

not many here are docs and im sure none are your docs.

i understand the frustration with the way some nurses dose your warfarin. (i have been expierencing this myself lately.)

has your doc been writting letters to your ins to determine medical necesity? my ins put me in contact with Sterling Medical, you need to talk to them (Actually talk to Paul) he knows whats going on! they will fill out everything needed and then your doc just needs to sign it. they provide a great mail order system and i believe you can get any meter that you are comfortable.

hope this helps! if you want Sterling Medical's number then send me a IM, i will even give you Pauls Ext... without him i dont think i would have ever gotten a meter! this is my first week having my INRatio 2! and it is nice to know that i can test every week without the nurses saying that i ONLY need to test monthly!

did any of that make sense? good luck mary!