Dosing Logic

[Ross]

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.

Yes, I think that's what most of us did, but we can't tell people to do it. We have to let them fumble around and decide it for themselves. In time, they will.

 

[BigOwl]

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.

Aye aye, Cap'n. I'll call into the nurse tomorrow.

 

[aussiemember]

Just a note about trusting people in authority. I too, have always been a strict rule follower and done what I am told. While I am self testing I am also getting lab checks as well just for a few weeks. I actually challenged the lab person because they kept wanting to lower my dose when I was consistently in the low 3's (3.1, 3.2) with my range being 2.5 - 3.5. We then discovered that their computer inaccurately had my range at 2.0 - 3.0!!! So it doesn't hurt occasionally to question what is going on

 

[donnag131]

Hi Bigowl. Glad to see you devoured info on Al Lodwick's site. I too have poured over much of that info and found it very helpful. One thing that might be of interest for you that I found on his site concerns yogurt, seeing how you said you were going to start snacking on it with your morning meds. See if you can track down the questions about probiotics, which are found in yogurt. There is a possibility that probiotics might increase the amount of Vitamin K production in your body, therefore it can lower INR.

When I was is the hospital after my surgery, I was eating yogurt for breakfast and lunch every morning. My INR was barely budging upwards, and they kept me in for 11 days because of it. Finally one smart staff member mentioned something about how maybe it was the yogurt that was keeping my INR level down.

I still eat yogurt every day, lots of leafy greens daily, and get tons of exercise. I just take a very high dose (145mg/weekly) because of it, which is no problem at all.

 

[BigOwl]

Thanks, Donna. I have been doing the yoghurt thing--but not all that much, and it's only got 7% of the mdr in it. However, combined with the senior multivitamin, that might make a difference. I can easily forgo it for a few days to see. I've been trying to focus more on eating healthfully--so that I've actually got a diet to dose--but a little tweak like this probably couldn't hurt and it might help. I'm trying to be fairly conservative in my eating habits until I'm stable, and have taste buds back, so this is a cheap and easy adjustment. The multivitamin has been factored into my treatment, but the additional probiotics might put a kink in things at this stage.

Many thanks for the comments and perspectives. I'm determined that the warfarin issue will disappear as an "issue" as soon as possible, and that it will just be part of my normal routine. Getting there is tougher than I thought it would be, but every day I learn a little more and am confident that I'll strike a balance between clinical requirements and emerging protocols, and I won't even have to worry about nuns whacking me with a ruler to get there.

 

[catwoman]

I have 1-2 containers of yogurt a day (usually Yoplait fat-free) to help get in my calcium servngs. Sometimes I don't have any yogurt. However, I haven't seen any significant changes in my INR whether I eat it or not. What I buy has acidophilus in it; not sure if that's the same as probiotics.

 

[ALCapshaw2]

I forgot to mention that AL Lodwick is a member of VR.com and monitored the AntiCagulation Forum for several years while he was running his Clinic.

I believe he will still respond to e-mail inquiries when he isn't giving lectures to Medical Professionals (and interested patients) on 'How to (properly) Manage AntiCoagulation'.

Ross even posted a picture of Himself having dinner with AL Lodwick when AL was 'in the neighborhood'. This might be a good time and place to re-post that photo Ross

'AL Capshaw'

 

[Cris N]

After my OHS my cardio's office was 'managing' my testing & dosing and doing a horrible job of it. I found this site about then and realized quickly that they didn't have a clue - even questioned them a few times when the dose change didn't make sense. Soon after that I had an appt. with my internist who suggested that I move over to the Anti-coagulation clinic that their practice maintained. I did and found that Margaret, 'the Coumadin nurse' was simply wonderful. She used a Coaguchek S and helped me learn the dosing. Within a few weeks she was asking me what I thought my dosage should be based on test results. Her method of management was very similar to what you find here with experienced self-testers/self-dosers. She was quite pleased when my insurance finally approved my monitor. She wasn't afraid of losing business - had too much to handle anyway. What a shame that there aren't more competent people like Margaret to either manage ACT or help guide patients toward self-management.

 

[Blanche]

BigOwl

BigOwl

In 2000, my husband had a serious problem with his INR. His INR was much too low, so after 10 years of successful anticoagulation he had a series of strokes.

After many weeks of hospitalization, physical and other therapy, when he returned home his anticoagulation was monitored by his Cardiologist and the Cardiologist's many partners... Al was to test weekly at the lab and he did. But, up jumped the devil when different doctors read his test results. His range, because of several strokes, was 3.0 -4.0. And that surely did confuse the hightly educated, experienced cardiologists in the practice.

Al's Cardiologist, the founding member of the practice and president of the practice, said Al's INR should be 3.0-4.0. Imagine my surprise when one of the doctors in his group said, "Have him hold for two days and test in a week>" He wanted Al to hold because his INR was 3.6...Another doctor wanted him to hold one dose because his range was too high...It was 3.0.

Years later, after the Cardiologist opened his own Coumadin Clinic at his (3) offices, he said...more than once...I don't know how the hell we didn't kill somebody before we got the monitor....

Currently, the largest practice in our area, with many more than 18 Cardiologists, many of which work at various hospitals, all use the very same "point of care testing" that is available to patients. And, they all still have their own ideas about the approptiate range for patients.

Just food for thought.

Blanche

 

[ALCapshaw2]

Aye aye, Cap'n. I'll call into the nurse tomorrow.

Big Owl -

I'm refraining from offering advice for awhile, BUT,
I am curious about how many days your INR has been below 2.0
(and how may more before you reach 2.0).

I would also be Very Interested in knowing how many days your AntiCoagulation Manager thinks it is safe for you (and/or all / any other patients) to go with an INR below 2.0

I'm not being facitious, I'd really like to know what Doctors and Clinic Managers believe is a "safe period" for INR to be below 2.0

This Question comes up not only for patients who have just been put on anticoagulation, but long term Coumadin/Warfarin patients who have to go OFF Coumadin/Warfarin for Invasive Procedures (e.g. other surgery) and then come back on afterwards.

'AL Capshaw'

 

[Lisa in Katy]

BigOwl, I can understand why you might be a little nervous. You will figure it out. I wondered why they started you on such a low dose because I think 5 mg daily is more normal, but when you explained your thyroid condition, I got it. Although the aspirin doesn't affect your INR, it will help prevent strokes, so that's a good thing. My Coumadin manager, who also is a fantastic Echo tech, and I work very well together. He'll say "Your INR is 2.2." and I'll say "Isn't that too low?" He'll say "Well, it's not too far off and as long as it isn't a trend..." I'll say "But what if the first symptom of a trend is a stroke?" He'll say "Well, you're right. Why don't you take x mg extra 2 days a week and we'll see where you are in 2 weeks." I'll say "Good idea. Thank you." I trust him implicitly on Echos, but I trust myself more on Warfarin. I don't want him to know that though, so I make sure I lead him in the right direction. That way he doesn't put any nasty notes in my chart!

 

[Ross]

I think that listening to you doctor's or a nurse's or an anticoagulation clinic tech's recommendations, ignoring them, and doing what you learn here or from a dosing chart is doing a disservice to all this person's patients who actually do what they're told. If you are doing something different, and bring your INRs into range, you MUST tell the caregiver how you did it. Otherwise, they'll continue blindly dispensing potentially fatal advice.

Mark you yourself are new to this and have yet to self test. While what your saying makes perfectly honest sense, in the real world, it can have very harmful effects.

Follow the Chain of Command rules apply here.
Cardiologist or other is the commanding General
Coumadin manager is second in command
Patient is expected to follow and carry out those orders. even if it means sacrificing their lives.

To present to the second in command that you may possess skills better then theirs, is a slap in the face and equivelant to striking an officer. What happens now? Your court martialed. Big Red Flag in patients record saying "NONCOMPLIANT" or "RENEGADE." Recommendation=Discharge.

Now this patient has to find someone else to manage their care and for some, that may be a blessing, but for most, it leads to yet another incompetent manager and the cycle is repeated.

I'm not condoning that anyone deviate from their managers instructions, unless they are proving imcompetent, then they must take the bull by the horns and take matters into their own hands for their own personal safety.

I tried this very thing with my first clinic. Even being diplomatic and making simple suggestions caused an all out nuclear war. I got fed up. I presented my documention on how and what I did vs what they told me to do, to bring myself in range when they had already stuck my veins repeatedly for 2 months and I still wasn't doing anything but see sawing up and down. There was no middle ground or even the hint of understanding. It was their way or no way.

The funny thing about this whole episode was when I presented some of Al Lodwicks information and it still didn't matter to them in the least. I switched clinics and started going to my Cardiologists clinics instead, because they used fingerstick testing.

Guess what? This very same nurse had quit her job at the old clinic and was now at the new. We both sort of just eyeballed each other for a minute, then she broke out with a smile and apologized to me for all that she had put me through before. She explained to me that she was following a protocol that was made by one of that clinics "Experts". She never realized how wrong that "Expert" was. On her desk was just about every article from Al Lodwicks site in a binder. She too, had seen the light and was now doing the same thing we are trying to teach people here. She has been doing an excellent job ever since. In fact, she's the one that signed off on my home testing. I had to demonstrate to her that I could perform the test on myself and get reliable results. We've been good friends ever since.

For her at the other clinic, it was pure hell. She wasn't sure what she was doing was right, but that's what the doctors told her to do. She said that even though I disobeyed her and took matters into my own hands, then provided proof of what I'd done, it just blew her away.

It's true, anyone can home test, but not everyone is capable of self dosing. For those that can, (and may have too) we are simply trying to teach you what those managers should have known all along.

 

[BigOwl]

I really do appreciate all the input--it's all been helpful, and it's given me some directions for research. I'm going to have a list of questions a mile long when I see my surgeon next week. I'm pretty confident that he's a fairly progressive guy, especially since he brought up home monitoring almost immediately, before I even asked. I'll put Al's questions on my list, since they're important and have ramifications beyond my own therapy.

Cat: the yoghurt I was eating was Stonybrook Farms organic probiotic nonfat. It has six different cultures in it and the only real nutrient value listed is Potassium. I was eating one little carton of this a day to help with stomach issues (I didn't want to take antacids; I'm already a walking pharmacy) associated with my lack of appetite. So I'm eating cereal or an egg and toast for brekkies until I get stable and then will reintroduce things slowly.

 

[catwoman]

BigOwl:

It's unlikely that just one 6- or 8-oz container of yogurt a day will affect your INR.
Al Lodwick has something about probiotics and warfarin at his website.

http://www.warfarinfo.com/probiotics.htm

 

[ALCapshaw2]

I really do appreciate all the input--it's all been helpful, and it's given me some directions for research. I'm going to have a list of questions a mile long when I see my surgeon next week. I'm pretty confident that he's a fairly progressive guy, especially since he brought up home monitoring almost immediately, before I even asked. I'll put Al's questions on my list, since they're important and have ramifications beyond my own therapy.

I was hoping you would ask your Coumadin Clinic Nurse what their policy is regarding INR's under 2.0 since they are the ones prescribing Coumadin/Warfarin dosing.

An order for Bridging with Lovenox can come from the Coumadin Clinic or Cardiologist or Surgeon, depending on the circumstances and inputs from all 3 sources would be of interest.

'AL Capshaw'

 

[Ross]

Al I know this isn't really helpful, but coming from my Cardio's mouth, at least for Aortic position, the risk of clot is low, but it is a risk that should not be taken. He figured I could get away with up to a week without some form of anticoagulation, but he certainly wouldn't suggest trying it.

 

[Marty]

The " handoff" all important

The " handoff" all important

This case of Big Owl sort of exemplifies what my surgeon told me ten years ago. In the early days of heart surgery patients stayed in the hospital 2 or 3 weeks. The surgeons had time to regulate the patients coumadin dose and send them home pretty well stabilized and knowledgable. Now , patients, as I did, go home in four days and the warfarin regulation is handed off to a variety of managers many of whom simply don't know what they are doing.
My advice to Big Owl is try to find a good clinic run by responsible people. It can be a nurse or a pharmacist. Most doctors I know are too busy to do it and often delegate ACT to a nurse ( or secretary ?). At my Kaiser clinic pharmacists handle ACT and do a very good job of it.

 

[BigOwl]

BigOwl:

It's unlikely that just one 6- or 8-oz container of yogurt a day will affect your INR.
Al Lodwick has something about probiotics and warfarin at his website.

http://www.warfarinfo.com/probiotics.htm

Well, when that's a significant portion of what you're eating, all those little critters might make a difference, especially on a really slow metabolism. I did read Al L.s stuff on probiotics, which is what made me decide to eat something else until I've got a better idea of what's going on. I also have really good questions to ask when I go in again.

And, Marty--the clinic I'm going to has about the best reputation in the area. I've spoken to other patients who are now stable, and their situations were different from mine. I'm apparently a little on the young side to have chosen a mechanical around here (according to a couple of sources, 65 is a more usual opt-for-mechanical age. I'm only a little over 61.) The other valvers I've met all have tissues. But I'm odd in other ways, too, especially in that I had a CABG very young. So lots of different things seem to be gumming up the works. The more I learn, though, the better I feel about how things are shaping up. I'm also rather more assertive now than I was a week ago (thanks mostly to you folk), so that should help. I've found that the smarter they think you are, the better the answers, and the more reasonable people can be.

Al: your question is #1 on my list.

 

[Lisa in Katy]

BigOwl, Generally the older you are, the more likely they are to recommend tissue. Tissue lasts longer in older people and Coumadin is more difficult to regulate.

 

[ALCapshaw2]

Big Owl-

Using a Gradual Increase in Dosing is a safe but SLOW approach to your 'Stable Dose'. In Engineering, it's called an Overdamped Response.

Overdosing causes an Underdamped Response which results in the familiar Overshooting / Undershooting (Roller-Coaster) Response. It can get you there quicker IF the manager understands how to control the 'stimulus' (which FEW if any anti-coagulation managers seem to know how to do, assuming YOUR body's response is predictable).

Bottom Line: "Slow and Steady Wins the Race"
and SMALL changes ease you back into range when there are minor variations.

Personal Footnote: If my INR was going to be below 2.0 for 4 or more days, I would want to be on Lovenox Injections as a "safety net" to prevent clotting until my INR came back into my designated "theraputic range". With an INR of 1.7 or 1.8, you do have some protection, but most of us (who have been on Coumadin for awhile) feel more comfortable being a bit higher. It's a wide 'gray area' with no sharp lines of demarcation.

'AL Capshaw'