Does this sound right? Dosage, testing, etc.

[Marge]

For atrial flutter, I am on warfarin with a desired INR range of 2.0 to 3.0. I've been taking the same dosage since I started back in early May: 5 mg every day except Tuesday when I'm supposed to take 7.5 mg.
I've had three blood draws so far:
May 9: 1.8
May 17: 2.3
June 7: 2.4
I have been told to go back for another blood draw on June 28. (Apparently after the second draw showed me in range they decided it was enough to go every three weeks.)
My questions:
- Is the desired INR acceptable for someone with a valve repair and atrial flutter?
- If between 2.0 and 3.0 is the standard, how desirable is it for someone to be on the low side of the range?
- Are blood draws every three weeks standard for this condition?
- What, if anything, should trigger a call to the anti-coagulation clinic prior to the next blood draw on June 28?
I'm thinking specifically of the fact that I am currently taking an antibiotic, cephalexin (keflex). My primary prescribed it for a respiratory infection on June 9. He said he would not normally prescribe an antibiotic for a respiratory infection but was doing it because of my valve. I am taking it 4x a day -- 40 capsules -- so I'll be taking it through Monday if I finish up all the capsules. My primary is well aware I am on warfarin -- we discussed that when I went to see him for the respiratory infection -- but we didn't discuss any interaction with warfarin. I looked up cephalexin on the net & it seems to indicate there could be some interaction.

 

[geebee]

Marge,

A couple of things come to mind. Cephalexin always increases my INR. I take it for dental work and/or bacterial infections as it is the only antibiotic I can tolerate. I would test late this week just to be sure it hasn't increased your INR too much.

I don't know the clotting risk of atrial flutter. I know it is less than a-fib. I have a mechanical MV & am in a-fib so I keep my INR around 3.5. I think Al should address your issue since you don't have a valve to factor in the equation.

Hope this helps some.

 

[Guest]

For atrial flutter, I am on warfarin with a desired INR range of 2.0 to 3.0. I've been taking the same dosage since I started back in early May: 5 mg every day except Tuesday when I'm supposed to take 7.5 mg.
I've had three blood draws so far:
May 9: 1.8
May 17: 2.3
June 7: 2.4
I have been told to go back for another blood draw on June 28. (Apparently after the second draw showed me in range they decided it was enough to go every three weeks.)
My questions:
- Is the desired INR acceptable for someone with a valve repair and atrial flutter?
With an aortic or tissue valve, yes. Mitral mechanical, no
- If between 2.0 and 3.0 is the standard, how desirable is it for someone to be on the low side of the range?
I'd rather see you on the high side.
- Are blood draws every three weeks standard for this condition?
I'd probably lengthen it out to at least 4 weeks.
- What, if anything, should trigger a call to the anti-coagulation clinic prior to the next blood draw on June 28?
Bleeding
I'm thinking specifically of the fact that I am currently taking an antibiotic, cephalexin (keflex). My primary prescribed it for a respiratory infection on June 9. He said he would not normally prescribe an antibiotic for a respiratory infection but was doing it because of my valve. I am taking it 4x a day -- 40 capsules -- so I'll be taking it through Monday if I finish up all the capsules. My primary is well aware I am on warfarin -- we discussed that when I went to see him for the respiratory infection -- but we didn't discuss any interaction with warfarin. I looked up cephalexin on the net & it seems to indicate there could be some interaction.
It usually only happens when a person does not absorb it very well and instead of getting into the blood, it lays in the intestine and kills the bacteria there instead. If it is absorbed, there is no true interaction.

My replies are above in red.

 

[Marge]

Thanks, Al. I talked to the Pharm D who manages my case at the Kaiser anti-coagulation clinic, explained about the respiratory infection and the antibiotic & she said, That should be OK, continue the same dosage & keep the June 28 blood draw appt as already set. She also didn't think the Tramadol (that my primary prescribed as an occasional painkiller for headaches, etc., since tylenol doesn't help me) would be likely to affect my INR (as long as it remains just "occasional").

So, so far, I seem to be doing pretty well on keeping in range without having to test more often than convenient for me (once every three weeks is OK for me, but I will see if I can get them to go for once a month if I am in range next time) and without messing around with dosage changes.

And, the clinic seems to have figured out how to get blood out of me without both me and the lab tech crying from sheer frustration! They now get out the butterfly needles as soon as they see me come in. And one of the techs told me to drink lots of water the night before & the morning of the test, and that seems to help. It is funny that nobody mentioned water before.

So I am "learning to live with coumadin." Although not loving it. Since I know it only helps me avoid clotting and strokes, and does nothing for the underlying a-flutter, I still have to confront my cardio on how to deal with that.

I still have no symptoms -- that I am aware of -- of the a-flutter. I only know about it from the cardio's diagnosis, based on the EKG and the Holter. (No palpitations, no pounding, no irregularities that are noticeable to me.) It is frustrating -- having to take this drug that has to be so closely monitored, for a condition that I am otherwise utterly unaware that I have.

 

[ALCapshaw2]

Marge,

Aren't there any Coumadin Clinics in the greater San Francisco area that use one of the Finger Stick Testers?

If not, maybe you should tell them to order some from ALABAMA and we'll put them on the next mule train heading west!

Ask your cardio if there aren't some medications that target A-flutter. I was put ona low dose of Sotalol (generic for BetaPace) which targets Atrial Fibrilation (wonder if it would also work on A-Flutter). Worked for me.

Good Luck,

'AL Capshaw'

 

[Marge]

Marge,

Aren't there any Coumadin Clinics in the greater San Francisco area that use one of the Finger Stick Testers?

If not, maybe you should tell them to order some from ALABAMA and we'll put them on the next mule train heading west!

Ask your cardio if there aren't some medications that target A-flutter. I was put ona low dose of Sotalol (generic for BetaPace) which targets Atrial Fibrilation (wonder if it would also work on A-Flutter). Worked for me.

Good Luck,

'AL Capshaw'

Re fingerstick clinics: I'm sure they do exist around here, but my coverage is with Kaiser. Kaiser (at least in the Diablo region where I am) does not have any clinics that use the finger stick method. The Kaiser lab where I go is about 10 minutes drive from my house. So going there is very convenient. Now that they have figured out how to get blood from me reasonably efficiently, I don't think I want to go farther afield -- where I'd also have to pay for the privilege. Whereas I have no co-pay for tests at a Kaiser lab.

Re medications: sotalol -- would that be a beta blocker? I'm already on one beta blocker, carvedilol (plus an ARB, cozaar); not sure what another one would add to the mix.

In your case, does the sotalol stop the a-fib or just control it? When my atrial flutter was picked up on the Holter monitor, my cardio mentioned the possibility of surgical intervention, followed by anti-arrhythmic medication, but indicated that he felt my a-flutter was quite well under control & not particularly dangerous at this point (except for the potential of clotting/stroke). So he thought the risk/benefit ratio of invasive treatment & anti-arrhythmics wasn't very favorable. But I'm planning to talk to him about all this again as soon as I get the chance.

 

[ALCapshaw2]

Yes, Sotalol/BetaPace is a Beta Blocker that targets A-Fib (not sure if that includes A-Flutter). I was previously on a low dose of Toprol XL which worked for several years until my Mitral Valve Stenosis became more severe.

As you seem to be aware, there are two theories of management, Rate Control (milder Beta Blockers) with anti-coagulation, and arrhythmia prevention with an anti-arrhythmic drug.

Sotalol is an anti-arrhythmic drug. It took a few weeks for me to 'adjust' to it. At first there was some dizzyness, especially following rapid head movement, but that eventually went away. Theoretically, one could go OFF anti-coagulation once anti-arrhythmic control is established.

'AL Capshaw'

 

[Georgia]

Marge, in addition to drinking a lot of water prior to blood tests, if you take a diuretic, have your blood work prior to taking the diuretic. Makes a difference for me.

(from the one who has one vein that will share its blood)