Dosing Logic

[BigOwl]

I had my second check this morning and I'm still at 1.7. So the tech has prescribed 2 mg. Mon, Wed, Frid, Sat, and 1 mg on the other days. I test again next Wednesday morning. I'm now nearly two weeks post op.

I told her that I still wasn't eating much because of my taste buds, but she said that would make the levels higher. I haven't lost or gained any weight (probably because my metabolism is at a standstill from lack of real exercise), and am trying to make sure I eat something nutritious at every meal. I'm also going to start snacking (yoghurt with the morning meds, bowl of cereal later, small sandwich or bit of leftover casserole at lunch, a yoghurt and/or or fruit later, dinner with the hubby, maybe a small snack with the 10 pm news) to keep my blood sugar from fluctuating too much.

How will exercise affect my INR (assuming an increase in metabolic activity)? I really want to start on the recumbent bike, since my heart rate is staying at around 75 and my BP's good. I had a great night last night--slept through from about 11 pm to 6, and feel worlds better today. And no, I'm not overdoing it.

Just wanted to appeal to the Board of Wisdom to see what y'all think of the warfarin regimen. I see my surgeon next Tuesday and would like to have some appropriate questions on hand.

 

[catwoman]

What was last week's dosage per day?

Once you start eating more and better, you'll probably need more warfarin. Fats and oils contain vitamin K, so when your appetite improves, you will probably be taking in more vitamin K through fats and also through other food sources.
Ditto with exercise. When you become more active, you'll need more warfarin. Exercise will decrease the INR because it increases blood flow, causing the blood to take more trips through the liver, where it is metabolized.

 

[catwoman]

BigOwl:

What's the story behind "BigOwl"? Anything to do with Garland High School? (Just curious. My two nieces and nephew graduated from GHS.)

 

[Ross]

Yes, what was last weeks dose?

To me, it doesn't sound like this person is being aggressive enough and you need to contact your doctor about getting lovenox until your in range.

 

[BigOwl]

They started me off with 1 mg./day when I left the hospital (Tuesday, 4/14). I didn't have it checked until that Friday (due to screwups), and it was 1.7.

The coumadin clinic tech prescribed the following: 3mg x1, then 2 mg Sat, Tue, 1 mg. rest of the week.

Today's check showed 1.7. and a different tech prescribed 2 mg. Mon, Wed, Fri, Sat and 1 mg. the rest.

I think the comment about the food was about general amounts rather than specific foods. There are charts on the wall that show the effects of certain foods on levels, so I doubt that these guys (a coumadin clinic in a major heart center affiliated with Baylor) are too far in the dark.

I just posted a comment to Al on another thread about being on .325 enteric aspirin still (it's on my release papers to continue). Is that affecting the INR?

Cat: the owl business is from my surname which as originally spelled in German meant "Owlfarmer." I started using it for all my web stuff--blogs are all "owl's something" or something to do with owls. BigOwl is also my moniker on the Serenity Movie forum (hence the hat), but you'd have to be a Firefly fan to get that part of it.

 

[Ross]

Asprin works differently on the plateletts. It has no effect on INR.

I don't know who did your first dosing, but that is NOT the proper way to go about it. This last person seems more in tune, but still not nearly aggressive enough. Give me a minute to think what all you've said and then I can say what it should have been done.

If I did this right, you only had 10mg for the week and still only had a 1.7, then this guy makes you take 11mg for the week.
10 + 20%= 12mg and your still not going to be near range. I'll bet on it. Adding 1mg when your this low is not going to do much of anything.

They need to move you to 2mg daily and test in a week. If your range is supposed to be 2.5 to 3.5, I'd go 3mg everyday for a week.

 

[Bina]

1mg per day...??? It really sounds like the clinic is terrified of dosing you enough.
My dosages are very low compared to many.......I take 3mg and 2mg ( 18-19 mg weekly).
I'm sure that you've got to take at least the 2mg daily for a few more days....where are those Lovenox shots?

 

[catwoman]

They started me off with 1 mg./day when I left the hospital (Tuesday, 4/14). I didn't have it checked until that Friday (due to screwups), and it was 1.7.

The coumadin clinic tech prescribed the following: 3mg x1, then 2 mg Sat, Tue, 1 mg. rest of the week.

Today's check showed 1.7. and a different tech prescribed 2 mg. Mon, Wed, Fri, Sat and 1 mg. the rest.

That dosage change isn't a change. It's 11mg a week (2X4 (8) + 1X3 (3) = 11). Same as what you were taking (3X1 (3) + 2X2 (4) + 1X4 (4)= 11mg).
Something's not right here. You need to be speaking to an anticoagulation RN or an MD.
I've been underwhelmed by lab techs at doctors' offices and coumadin clinics.

 

[Ross]

I think the comment about the food was about general amounts rather than specific foods. There are charts on the wall that show the effects of certain foods on levels, so I doubt that these guys (a coumadin clinic in a major heart center affiliated with Baylor) are too far in the dark.

For Gods sake, don't even think about using a wall chart like they are. Dose the diet you eat, don't diet the dose they put you on. Food plays a very very small roll in INR management.

 

[Tbone]

For Gods sake, don't even think about using a wall chart like they are. Dose the diet you eat, don't diet the dose they put you on. Food plays a very very small roll in INR management.

Exercise has more of an effect on an INR than diet does.

 

[Bina]

Yes. My dose is a very steady 19 mg per week....but this past couple of months I was particularly sluggish, and so my current dose is 18mg weekly.
Time to get outdoors.

 

[BigOwl]

For Gods sake, don't even think about using a wall chart like they are. Dose the diet you eat, don't diet the dose they put you on. Food plays a very very small roll in INR management.

I wasn't. I was just using that to illustrate that they do know something about food. I, like Corinne, have "Dose the diet; don't diet the dose" emblazoned on my inner brain.

I have a call in to my cardiologist's nurse to ask about this stuff, but I have two observations to make before I go take a happy pill and a nap.

One is that, although I appreciate the wide experiential knowledge you guys possess and respect your expertise, some of us are military brats/Catholic school survivors with overdeveloped respect for authority. I have always done what I was told. I'm also sure that as soon as I'm on top of this and understand everything I need to, I'll be fine, but for the moment I do need to feel confident that the people who've been put in charge of my treatment, know at least something about what they're doing. I also am inflicted with a perhaps overinflated trust in physicians (grandfather was a DO/surgeon, father-in-law is a nationally respected oncologist, brother-in-law is an internist, sister and several cousins are nurses, etc.), so I do have a tendency to trust medical people.

The second is that I'm now experiencing some significant anxiety over this, when I had been doing pretty well. I know that's more me, than you, but I saw Corinne respond similarly on her thread.

It's pretty clear from what I've read that coumadin treatment has come a long way very quickly. That means that treatment protocols are in flux, and even clinics like mine may not be in on the absolute latest thing. But these folks have to do CME pretty frequently, so I expect they'll catch up. Meanwhile, some of us are caught between the two nodes of "current protocols" and "what the real users know" and I'm not sure we're all prepared to make choices along these lines--especially if we're still pretty highly charged and early post-surgery.

Thanks people. I appreciate what you're tyring to do for me more than I can say. But I think I need to back off for a bit, at least until I talk to the nurse.

Oh, and Bina, I'm going to take that nap outdoors.

 

[Bina]

Don't forget to nap in the shade.

 

[BigOwl]

Well, that didn't take too long. Heard back from the nurse and then talked to the head of the coumadin clinic, and both said that they really needed to bring me up slowly and see how my metabolism is going to affect my dose. Since I'm one of those classic metabolic syndrome types with hypothyroidism and bad BMI, they want to bring me up to my therapeutic level slowly rather than have to adjust downward if I were to rise too quickly. She said to gradually increase my activity level, keep eating (notably just healthfully--not staying away from anything), and not freak out. She said they were following pretty much the same protocol they were following in hospital and what they would be doing if I were still there (of course, I'd be getting my finger stuck once a day if I were still there). At any rate, I think I'm cool with it now and am no longer panicky (or the pill has taken effect), so I'm out to the back yard for a nap with the puppies in the nice warm shade.

 

[Ross]

I wasn't. I was just using that to illustrate that they do know something about food. I, like Corinne, have "Dose the diet; don't diet the dose" emblazoned on my inner brain.

I have a call in to my cardiologist's nurse to ask about this stuff, but I have two observations to make before I go take a happy pill and a nap.

One is that, although I appreciate the wide experiential knowledge you guys possess and respect your expertise, some of us are military brats/Catholic school survivors with overdeveloped respect for authority. I have always done what I was told. I'm also sure that as soon as I'm on top of this and understand everything I need to, I'll be fine, but for the moment I do need to feel confident that the people who've been put in charge of my treatment, know at least something about what they're doing. I also am inflicted with a perhaps overinflated trust in physicians (grandfather was a DO/surgeon, father-in-law is a nationally respected oncologist, brother-in-law is an internist, sister and several cousins are nurses, etc.), so I do have a tendency to trust medical people.

The second is that I'm now experiencing some significant anxiety over this, when I had been doing pretty well. I know that's more me, than you, but I saw Corinne respond similarly on her thread.

It's pretty clear from what I've read that coumadin treatment has come a long way very quickly. That means that treatment protocols are in flux, and even clinics like mine may not be in on the absolute latest thing. But these folks have to do CME pretty frequently, so I expect they'll catch up. Meanwhile, some of us are caught between the two nodes of "current protocols" and "what the real users know" and I'm not sure we're all prepared to make choices along these lines--especially if we're still pretty highly charged and early post-surgery.

Thanks people. I appreciate what you're tyring to do for me more than I can say. But I think I need to back off for a bit, at least until I talk to the nurse.

Oh, and Bina, I'm going to take that nap outdoors.

Everyone feels the same way as you do when you first start this stuff. Pretty soon you'll realize what were saying and then you'll know whether you have really experienced people managing you or monkeys throwing darts at a board. Most people find the monkey scenario going on. I was the exact same way when I started. I was apprehensive, scared to do anything against the clinics judgements etc. When your getting veinous sticks 2 and 3 times a week and the dose changed just as much and getting no where, then you realize like I did, that monkeys were throwing darts.

At first, When Al was still posting here (he still does on occasion) I thought he was nuts. After a while of all the needle sticks and still getting no where, I thought maybe this guy isn't so far off after all, lets give it a try. Wham Bam, I'm in range and stable within two weeks time. All I can tell either of you is that this method has not failed anyone that I know of and we've brought many people here, into range and stable, when most of their clinics or doctors could not. I'm proud of that being that we are only home testers and self dosers and not professionals.

It's a well known fact that the majority of professional managers cannot properly dose Coumadin. Al is out there right now, busting his butt all over the country trying to get these people educated. The largest problem currently are those teaching the student doctors the old ways and the old myths, because they themselves have not kept up to speed. You'll see it. I guarantee it!

I'd like to see these people on the same page in my lifetime, but I've been here 8 years and I see and hear the same thing from every new person every single day.

MR. LODWICK TEACHES CLASSES ABOUT WARFARIN THERAPY. THESE ARE DESIGNED FOR PROFESSIONAL CONTINUING EDUCATION BUT ANYONE INTERESTED IN WARFARIN THERAPY IS WELCOME TO ENROLL. YOU MUST REGISTER WITH CROSS COUNTRY EDUCATION OR PAY AT THE DOOR TO ATTEND.

UPCOMING CLASSES ARE SCHEDULED FOR

Springfield MO (2 classes)

St. Louis MO (2 classes)

Kansas City MO (2 classes)

Wichita KS (2 classes)

Fresno CA

San Jose CA

San Francisco CA

Oakland CA

Sacramento CA

Reno NV

Smithtown (Long Island) NY

Flushing (Queens) NY

Manhattan (Times Square) NY

Parsippany NJ

New Brunswick NJ

Atlantic NJ

 

[ALCapshaw2]

For the benefit of newcomers to VR.com, Ross is speaking of AL Lodwick, Registered Pharmacist and Certified AntiCoagulation Care Provider who managed his own Coumadin Clinic in Pueblo, CO until a year or so ago when he retired. He now teaches AntiCoagulation at Seminars around the Country as Ross listed above.

'AL Capshaw'

(just another Heart Patient on Coumadin/Warfarin)

 

[BigOwl]

Well, I'm better now. Got my knickers in a bit of twist there for awhile, but the nap helped, and so did the happy pill.

I think what I'm going to end up doing is that as long as things progress apace, I'm going to be a good girl and mind my Ps and Qs so I can get approved for home testing asap. I see my surgeon on Tuesday and will raise your concerns with him, and suggest that some of the clinic staff be sent to one of the seminars. Jett's pretty hot stuff around here, and he may well be able to make something like that happen.

I'll report back in next week (since I'm actually eating meals and beginning to get some exercise, my body may have decided to do something other than just stagnate by then), after I talk to the doc and have the next check.

And Al, thanks for clarifying the Al's (can I call you Al?). I knew the difference, but it might indeed be confusing to the newer folk. Of course, I devoured Lodwick's website almost immediately on hearing about it. My only complaint is that he could use some web design help. But I will definitely put in a plug for the seminars when I see Jett, and again when I see my cardio early next month.

Thanks for everything, Ross--et al (there's a joke in there somewhere . . .)

 

[corrineinwa]

Well, I'm better now. Got my knickers in a bit of twist there for awhile, but the nap helped, and so did the happy pill.
....

Welcome to my world - tell me more about the "happy pill"!

Seriously, I'm sorry you had a bit of upset over the Coumadin thing. Having said that, it was enormously helpful for me to see that patient or caregiver, it's a normal reaction.

I can't contribute a thing to the technical side of this conversation but I can send you a cyber-hug.

 

[Ross]

You'll both soon being contributing to the technical side. It comes with the territory.

BigOwl, I'm still very concerned that your running around under 2.0 without any protection. Please talk to your doctor about Lovenox until your in range.

 

[Herb M]

Many people on this site know more about dosing coumadin than most Physicians or clinics. Everyone needs to learn how to dose themselves rather than only relying on people in the medical profession.

My physician calls me after I have a blood test and tells what I need to do. I usually pay little attention to the instructions and determine what I need to do, if anything. Some of the instructons I have received are off the wall.