Coumadin Puzzle-What would you do?

[Nancy]

This is the scenario from Joe's latest hospitalization.

Joe's range is 2.5-3.5

On Monday, his INR was 3.3 and he has been taking 10-12 mg. Coumadin.

He developed diarrhea and at the same time developed CHF with ascites and some liver congestion.

By Friday, he had become very ill and was admitted to the hospital.

His INR tested out at 4.5 the day of admittance.

His Coumadin was held on Friday evening and also on Saturday evening.

By Sunday, he had lost at least 9 pounds of fluid and his stomach was no longer distended.

Sunday afternoon, his INR was 2.6

Sunday evening it was decided to resume his Coumadin and the Cardiology Intern on call was asked to determine the dosage. When she came into the room, she told us that Joe's INR range was 2-3. We corrected her.

She then made her recommendation for dosage.

Guess what her dosage should be.

I'll tell you what it was later.

 

[Ross]

Let me guess, she wants to cut it by 50 to 60%?

 

[LUVMyBirman]

Hummmmmm

Hummmmmm

Hi Nancy,

I am going to guess 8MG.

Recently my carido put the management of the Coumadin totally into my hands. Proved that his Coumadin nurse was making some poor choices. Long story.

His clinical nurse is highly educated and a great gal. She asked me if this was my first "run in" with the Coumadin nurse. She was really a stinker. And honestly....I had "run ins" frequently.
Have a feeling I was not the first one. Have not called the lab to see if she's still employed.

Good luck and keep us posted.

 

[JimChicago]

What do we win if we guess it?

The way you asked it - it sounds like it was something wierd - so I'll agree with Ross - - so I'll say 5 mg /day.

 

[Karlynn]

I'm guessing he was either told to go back on his previous dose, or they went wild the other way. I'll vote for 5 too.

PS- Joe is not allowed to initiate these kind of games anymore!!!!!!

 

[fyrfytr]

Hi Nancy,
I am going with 4mg.
Take Care

 

[Guest]

I'm not going to guess what she chose, but I'll tell you what I would do. I'd go back to the same dose. He really did not have a Coumadin problem and the ascites was corrected which was the cause of the slightly elevated INR. It is impossible to assess what role diarrhea played in this but it usually raises the INR also. So I think that the right answer is 10-12 mg/day.

 

[ShezaGirlie]

Oh come on Al...you're no fun...

Oh come on Al...you're no fun...

Logic sort of tells us that she ordered 5mg, but since she was obviously uneducated in Coumadin management, I'm going to guess she said 15mg! No rhyme, nor reason...

 

[Guest]

Half the world thinks I'm a smart alec and the other half thinks that I'm no fun. On average I'm OK.

 

[Tony]

I would say --- Go back to pre hospitalization dosage.

Tony

 

[Nancy]

OK, this is what Joe and I thought should have been done.

Joe was right in range before his ascites kicked up. With the liver congestion, his INR rose to 4.5. When the liver congestion improved he started to get lower, so that after holding for 2 days, it was 2.6, the bottom end of his range. At that point his liver congestion was improving rapidly. . We know about the 3 day lag until Coumadin gets into your system, so we felt that he would continue to drop for probably the next two days, making his INR go to dangerously lower levels. If 5 mg were prescribed, it would have a minimal effect and would not be high enough to bring him up to a normal range. He would then be untherapeutic for one more day than he should have been.

We felt that the dosage should have been 10 mg, since the raise in INR was caused by his liver congestion problem.

The Intern dosed him at 5 mg because she was afraid to "overshoot" and thought that he was "terribly high" at 4.5.

I think further that the second hold shouldn't have been done and he should have been given 5-8mg Coumadin on Sat.

Plus the Intern did not know the correct INR range for Joe, either she didn't read the chart, or she did not have a good handle on the correct level of anticoagulation for a double valver. She was a little unsure, but thought he should be 2-3. We corrected her.

We both expressed our concern, but of course, she did what she wanted.

When he gets discharged, the first thing he'll do is call his Internist who manages his Coumadin. I'll let you all know what the INR is in his first Protime post discharge.

 

[Ross]

Why is it always so predictable with these people? They always seem to swing to the opposite extreme when they should only reduce 5 to 10% and in Joes case, I think they should have left it where it was as he improved.

 

[Guest]

Sometimes you have to remind them that you have been involved with this since they were in 7th grade.

The youngsters take a while to come to the realization that you learn from your patients.

 

[Ross]

The youngsters take a while to come to the realization that you learn from your patients.

The conclusion I come to with this statement is that all, with the exception of yourself and not meant in a bad way, are youngsters. Seriously Al, every place around me is like that and listening to others stories, it's like that for them as well. I know it's not an exact science, but is it really that difficult for these people to figure out?

It's Monday and I'm cranky as usual, so pardon the sarcasm.

 

[Nancy]

The most surprising thing about this is that these things happen within the field of "cardiology care". I can't tell you how many people in the "field" are totally clueless. It's really shameful.

Isn't proper Coumadin management taught in medical school?

If you want to have some fun , next time you have an Intern evaluating you, ask them what your Coumadin range should be, and see how many of them know the correct answer, or even know how to figure it out. You'll see some major league tap dancing.

It might help that person be more aware of something they should study more closely. I think of it as a service to humanity

 

[mmcbroom]

With Mech aortic and donor pulmonary valves, my original cardio and surgeon put my INR at 2-3. But when I went to a new clinic after X-country move, 2 years later, they said it should be 2.5-3.5, which is correct? It all goes with what your coumadin care person was taught.

Good Luck with Joe's ###'s

 

[ccrawford]

The correct range using todays accepted practice is 2.5 -3.5. My cardio indicates that this is likely to change in the near future, however, down to 2.0-3.0. I'd use the former range until you hear otherwise. Chris

 

[Nancy]

By the way, upon discharge, his cardiologist (who was off during the weekend), upped the dosage to 10 mg for tonight.

Joe will have another Protime tomorrow with his Internist, so then we'll know what the INR is.

 

[JimChicago]

As an aside,
I recently got a copy of an article from Lancet 344 1994 p1337 - from my library to get a little article on CoQ10 and warfarin - next to it was a little note on diarrhea and warfarin - here's a quote:
"These events suggested that the diarrhea had caused malabsorption of dietary vitamin K resulting in an overdose of warfarin" Tis little note was based on anecdotal observation - not a study but also suggests decreasing warfarin during bouts of diarrhea.

 

[catwoman]

Nancy:

I carry one of the Coumadin leaflets in my purse. Am constantly whipping it out at restaurants, groceries. Has diarrhea listed as increasing INR.
Do you have one of those leaflets? (I'm sure you do -- you're an encyclopedia). I got it at my PCP's with a sample of Coumadin.