High INR with Prednisone

[Gary Miller]

I finally completed my regimen of antibiotics (Levaquin) and Prednisone for my severe sinus infection. As retired military I get PC treatment at the local base hospital. The military docs are sometimes hardcore about treatment and he prescribed 21 days of 500mg Levaquin and the last 5 days in conjunction with 60mg of Prednisone. Well my INR is finally up! I am usually at 2.2 to 2.6 and the Levaquin got me to 2.8 at 16 day mark. After 3 days of Prednisone it’s up to 3.5 now. I take 12.5 mg four days and 10mg the other three days. I called the Coumadin nurse and she advised me to take only 10 mg for the next 5 days. My Cardio called the house last night and thought I should skip a dose last night. He was concerned about the 3.5 being high and I had one more day of 60mg of Prednisone. I thought that if I’m taking 80mg of Coumadin a week that may be an 8 mg reduction or only 2.5 last night might be a compromise between the recommendations and he agreed. I told him I would test again Thursday to see which way it is going. Hope I didn’t ruffle any feathers here, they have been very good about my monitoring, but if is frustrating how different the instructions can be!

 

[Protimenow]

When you say that you take 12.5 mg for four days and 10 mg the other three days, I'm hoping that you're alternating the dosage from day to day. If you're alternating doses, your INR will probably be more stable than it would be with four days at one dose and three days at the other.

The antibiotic probably contributed to your INR rising -- after you stop the antibiotic, your INR will probably again drop slightly. (FWIW - an INR of 3.5 isn't all that terrible - especially if you're just a bit careful about bumps and bruises. A lot of us have ranges from 2.5-3.5 -- and we aren't bleeding to death. I don't think that skipping a dose would have made a lot of sense - 3.5 isn't all that bad)

I'm not familiar with any interactions between prednisone and warfarin.

 

[Freddie]

Taken from DrugDigest:

WARFARIN SODIUM (in Warfarin Tablets) may interact with PREDNISONE (in Prednisone Tablets)

Warfarin is generally used to prevent your blood from "coagulating" or forming blood clots. Although the cause of this potential interaction is not clearly understood, prednisone may alter the anticoagulant effect of warfarin. Based on information from one study and two case reports, prednisone may increase the anticoagulant effect of warfarin in some people and decrease its anticoagulant effect in others. This unpredictable outcome appears to be related to the individual and may also be influenced by when doses of prednisone and warfarin are taken. If these drugs are used at the same time, your doctor may want to monitor you closely when therapy with prednisone is either started or stopped. Blood tests can be used to make sure that you are getting the right amount of warfarin. If you are experiencing problems, it may be necessary to adjust the dose of warfarin.Discuss this potential interaction with your healthcare provider at your next appointment, or sooner if you think you are having problems.

FWIW, I wouldn't be skipping no dose, but slightly decrease it.

 

[Gary Miller]

Wow! Tuesday morning was at 3.5. I reduced my 12.5mg Tuesday dose to 2.5 that night, and my regular 10mg last night have a 2.5 today! Now that I'm done with the medication, I'm going to go back to the normal dosing routine and check it on Tuesday again. That was sure a quick drop. I'm now glad that I lobbied for the 2.5mg on Tuesday, instead of skipping it all together. It’s interesting that it takes a lot of Coumadin to raise my INR or keep me in range, but any reduction in dose would react that much. I have compared my Coagucheck XS to the labs here and it doesn’t vary more than .3 between the three.

 

[Protimenow]

It sounds like you're back on track, and the effects of the antibiotic and prednisone on your INR have diminished.

As far as your dosing goes - I'd alternate between the 10 mg and the 12.5 mg doses. One trick that I've used in the past is to take ONE dose on days with a 'T' in them (Tuesday, Thursday, Saturday), and the other dose on days with no 'T' in them. In your case, it would be 10 mg on the 'T' days, and 12.5 on the other days. This way, your INR should be more level than it would if you didn't alternate your dosing days.

For me, in the past, when I was taking two different doses, the 'T' day scheme helped to keep my INR pretty stable.

It's something that you might consider, too.

 

[slipkid]

Just came up here and searched for PREDNISONE, found this thread. I am aware that it interacts with warfarin and causes our INR to rise.

I've been on prednisone b4 for allergic reactions prior to getting my AVR and have had very bad experiences with it. Never thought I'd ever consent to take it again but am being "persuaded" to now by my Drs to treat a new condition (bell's palsy - not fun). Supposedly it can help relieve the symptoms and escalate the recovery but nothing is certain. I first said no way am I taking that poison again but they convinced me to try. Had bad reaction yet again on very first day and we are cutting down the dose but still....ok back to the point....I will be monitoring my INR every 2 days or so then making changes to my warfarin doses with my Dr's consent as needed.

Am curious to read other people's experience of prednisone with warfarin management. If you went up how much? Did the peaks remain for a period of time after prednisone was stopped or was it a big cliff falling down to a lower level on 1st day without it etc??

 

[Chuck C]

(bell's palsy - not fun

I have not been on prednisone since being on warfarin, so I can't offer any help there, other than to say that I believe that you are doing the right thing to test INR every 2 days once you go on the prednisone.

I am a little familiar with Bells' Palsy, as my stepdad had it. What I do remember is that nearly all who have it recover 100%, and he did as well.

Funny story with that. My stepdad and mom are in the car- he is driving. He pulls over and says that something weird is going on with his face. He has no control over the left side of his face. My mom, seeing that the left side of his face is drooping yells: "OH NO! YOU'RE HAVING A STROKE" Hearing this, he faints and does a face plant on the steering wheel. Well, now my mom, who caused him to faint from her reaction, is certain that he is having a stroke, is going hysterical and calls 911 and tells them her husband just had a stroke.

So, he had a few bruises on his face from colliding with the steering wheel, but no stroke. Bell's Palsy and after a few months he was 100% recovered, as I understand is the case with the vast majority.

Please keep us posted on how your INR reacts to the prednisone and best of luck in getting through this with 100% recovery.

 

[slipkid]

Thx Chuck.

That is a hilarious story (but NOT FUNNY AT ALL AT THE TIME OF COURSE!) about your stepdad. Good that he recovered. I think the stat is something like 80% of people recover in 2-3 months?? Whether on prednisone or anything else. I 4get. My Dr also is putting me on Valtrex even though I have no shingles rash, since that is part of the "guidelines" that they follow even if it makes no diagnostic sense.

When I first felt my face going south I knew it was not a stroke because I have already known people with Bell's Palsy and was familiar with it. So I didn't panic, had no other stroke signs. Couldn't even get an appt to see my Dr AT ALL anyways, had to wait 24 hours and settle for a nurse practitioner to confirm my own diagnosis (I did leave a msg with my Dr via their web portal right away with my symptoms and that I thought it was Bell's and he agreed, so I guess that does excuse the lack of not being able to even get an appt to see him, he just wanted me to come in and see ANYONE in the office that was available to confirm things first hand).

And as usual the Dr in his portal msg where he prescribed the prednisone, nor the nurse that I saw b4 starting it, told me a goddam thing about it reacting with warfarin. I had to bring it up myself and tell THEM I would be testing more frequently which they then said yes that is a good idea. Gotta love Drs, or at least our current healtcare system, where they only have 3 minutes to try to deal with every patient they see...

 

[Chuck C]

And as usual the Dr in his portal msg where he prescribed the prednisone, nor the nurse that I saw b4 starting it, told me a goddam thing about it reacting with warfarin.

The level of ignorance in the medical community, regarding drug interactions with warfarin, is stunning. I'm not sure if you've read my story on that, but I was put on amiodarone upon release from the hospital. Despite the fact that amiodarone's interference with warfarin clearance is well established, and there are published studies which suggest that my dosage of warfarin should have been reduced more than 40%+ proactively, based on my amiodarone dosage, I was given no warning about it nor told to reduce my warfarin dosage. The nurse practitioner who prescribed the amiodarone was oblivious to its effect, as was the pharmacist who prepared the prescription. As a result my INR went from 2.9 upon release to 9.7 within 3 days. I had to go on vitamin k to bring it back down.

It is really good that we have this forum so that we can share personal experiences and compare notes on such things.

 

[dwhist]

Over the last 2 years I took the z-pack for Prednisone for a bad knee and shoulder maybe 6 times. INR is to be in 2.5 to 3.0 range and do not remember having any issues with getting out of range. I test weekly with home machine.

I believe every body handles it differently.

 

[slipkid]

Thx for the feedback.

On testing after 3 days on prednisone my INR only went up .2 (2.4 to 2.6). Cannot even say for sure it was due to the pred yet.

Note that I had some bad side effects on 1st day of valtrex/pred and Dr correctly determined it was the pred that was responsible and cut my dose way down immediately. So it's very probable if I had not had the side effects & stuck with the original dosing my INR might be a lot higher now but who knows. Or could even be some kind of latency factor involved while body adjusts to pred, I have no idea.

Regardless I am testing again in 3 days. Unless it goes over 3.0 - or crazy high like what Chuck C mentioned above - I will be taking no action. And have been reporting the INR direct to the Dr himself this past week in addition to calling it into my INR service/biotelheart (oops, they did change hands last year, I 4get right now what their current name is, maybe Philips? again I 4get).