Found warfarin dosing protocol!

[catwoman]

Couple of weeks ago I queried here about a "new" warfarin dosing protocol that our PCP's office is using.
John had another INR test last Wednesday and was given a copy of the 2.0-3.0 guidelines. I googled and found the full chart.

http://intermountainhealthcare.org/alumniprojectfiles/2002-049.pdf

I find it more confusing that Al Lodwick's algorithm. Too many INR levels (9, as opposed to 5 on Al's chart) on the 2.0-3.0 range. It's also set up for increasing/decreasing by 1/2 or 1 tablet/week, rather than increasing/decreasing by 10/15% increments. (Guess this chart is meant to be used by folks who DON'T own calculators???)

Dosing charts are provided for 1, 2, 2.5, 5, 7.5 and 10mg tablets, with adjustments for 5, 10, 15, 20% increases/decreases. (However, I believe that warfarin/Coumadin also comes in 3, 4 and 6 mg tablets.)

John said the employee who does the INR tests mentioned something about not liking it when patients take 2 different strengths of tablets. The dosing charts explain why.

Take a look at Page 17 -- mentions about new revenue being generated -- "ave. of $27/visit" -- with the chart.

This chart is used by TexasHealth Provider Network, which is affiliated with Baylor Hospitals.

There's always more than one way to achieve a goal. However, Al's chart is eaiser to understand, use and it's so easy that even a caveman (or cavewoman) can use it.

 

[catwoman]

If you don't have Al Lodwick's chart, go to www.warfarinfo.com and buy one. It's only $5. Well worth it.

 

[RobThatsMe]

Hi CatWoman,

Some good stuff there, but I think it is used as a selling point to some clinics.

Also, If I am reading this correctly, if I test for the 2.5 to 3.5 range, and when they check my INR it tests within range, then they recommend not checking again for 1 month, and if during that check the INR is also in-range for the next month check, then they recommend not to check again until 2 months go by.

I monitor my INR weekly, and can see the swings in INR that can occur. I personally would never go 2 months between checking my range.

Also, there are some people that take Coumadin for "other" reasons than valve replacement, and in some of these cases, it is not as "critical" for the INR to be monitored, especially if in low doses. Perhaps this data is more geared for those people, and not valvers.

It will be interesting to hear from others on this information you posted.

To each his own.. but call me a pessimist regarding their recommendations here.

I did like the "Adjusting Coumadin to Achieve a specific range," chart, except that is for the recommended intervals between testing. And I also liked the daily pill intake chart for the amount of pill that you have prescribed, although the 10% increases don't seem to add up.

Rob

 

[catwoman]

Rob:

Supposedly using this chart, one of our PCP's colleagues adjusted my husband's warfarin dosage by only 5.5% when his INR was 1.5, with a range of 2.0-2.5 (yeah, narrow). Two days later I called to say that a 5.5% increase wasn't enough and that he would stay under range if he went with the advised increase.
I thought an increase of 10% was justified (even 12-15% would have worked just fine, if you bump the range to 3.0 from 2.5).

Our PCP's office yielded to my "expertise." His INR was almost in range last Wednesday -- 1.9. I increased the dosage a smidgen (John wrote it down at home), so he should be closer to 2.5 next week.

 

[Ross]

Just a quick review and I see things that kind of bother me. I think they're playing with the windows too close together. It's not the worst dosing I've seen, but I still see things that could cause swinging in there. I think their being too conservative in some approaches and will likely result in more testing.

 

[RobThatsMe]

Hi Marsha,

Good for you! It sure pays, and perhaps saves lives to stay on top of this medication.

I gather from some of the posts we see on here, the doctors, but mostly I think... in many cases, their receptionists, hmmm.. that could be a stretch but hey.... If they don't know how to manage Coumadin, nor realize the impact of their decisions.. perhaps they should be receptionists... They certainly have no business telling someone what dose to take... anyway.. they sometimes make some really poor judgments on dosages.

Glad to hear you questioned the dose, and I do thank you for your post. There is some easy guidance, I mostly don't agree with the time between checks. Also, I did find how they were managing the approximate percent increase numbers. They are going by managing it by either a whole pill or half pill dose, in which case the percents are off. For example, using the 5 mg tablet, for a 5% increase they bump the dose from 35mg per week to 37.and call that approx 5% when actually it is a 7.1% increase. In fact, 5% should be 36.75 mg, or almost 1 mg lower., or in the case of a 10% increase, they recommend 40 mg per week. . This is 1.5 mg higher than a 10% of 35 and is in fact actually a 14.3% increase.

Ohh well, all these percents make my head spin too!

Happy Monitoring!

Rob

 

[ClickerTicker]

In a quick skim through this, I found six obvious spelling mistakes. I hope they've taken more care over the numbers...

 

[catwoman]

I had googled Hickl's name -- he's an internist. Don't know if any of the other doctors whose names are attached to this are in the cardiac field, or are just PCPs/GPs/internists. None are identified as pharmacists or CACPs.

My husband & I discussed the chart vs. Al Lodwick's, and we agree that it's easier to adjust by percentages over a week's dosage divided by 7.

 

[doyo]

One thing that caught my attention on this chart is the instruction to hold 3 days dose for INR 5 - 6 with no bruising / bleeding. I know INR above 5 should be dealt with. (Range of 2 - 5 are considred safe zone)
However, many members who take high dose report that their INR drop by 50 % with each skipped dose. My wife takes 7 mg / day and we found even at this dose, her INR drops 50% with one skipped dose. 2 skipped doses would drop her INR from 5 to around 1.2 And it takes 7 - 10 days to bring it above 2.
And it says if you are within the range, go to monthly schedule and if 3 monthly readings within the range, re-check every 2 month. In my opinion, This is just plain crazy and wrong. INR can vary between tests in 2 months time and you would not know about it for a long time. There are some members with seemingly stable INR and the monthly check who developed the stroke. I think their doctors told them after the stroke that it could've been prevented if they were tested more often.

EJ

 

[Blanche]

Well, doyo, my husband is one of those folks who tested monthly for a bit more than ten years with no problems whatever. Then, up jumped the devil and he had two back-to back strokes (December 15 and December 22). He had tested 27 days prior to the first stroke.

His doctors, one cardiologist, one internist, and one cardiovascular surgeon, all agreed that had he tested more frequently the strokes could have been prevented.

We have home tested since 2001 and plan to continue.

Kind regards,
Blanche

 

[catwoman]

I will print off the responses to this thread & have my husband give it to our PCP when he has his physical next month.

 

[doyo]

Marsha,

http://www.aafp.org/afp/990201ap/635.html

After Al's chart, I like this one from American Family Physician the best.

You might want to print it out and give it to your husband's PCP.


It gives a really good overview of how the drug works and things to watch out for such as drug interactions, etc.
It also warns about the danger of overloading the dose.
By overloading, they mean the practice of some doctors giving a huge dose (10mg or more) to new patients in "hopes" of raising their INR quickly. But according to this article, that practice is ineffective and potentially dangerious because it could increase the possibility of the clot formation.
According to this article, the initial dose of warfarin should approximate the chronic maintenance dose that is anticipated. In most patients, the average maintenance dose is 4 to 6 mg per day.

The article says once the patient's INR becomes stable then the testing interval can be increased to 4 - 6 weeks. I still think it is good idea to test more often than 4 week interval.

EJ