INR 4.8 and having bleeding problems

[Natanni]

2 years went by with minimal INR problems. Husband took 5mg 7 days a week/35mg a week; In August, things started to change with loss of family members and medication changes (namely, Zetia dc'd) and since then, Nathan has been pretty much out of range. For the past 6 wks, he has been doing 5mg 7 days/week with an added 2.5mg 4 days/week =45mg per week per coumadin clinic. One month ago he had a bleed in his arm. It looked like he had an eggplant hanging off of his arm. This happened while leaning on his elbow on his work bench. We checked his INR and it was ?4.2. His doctor dropped his coumadin to 5 mg per day for one week to allow the hematoma to be absorbed and he did fall to 2.3 after one week. His home INRs the last 3 weeks have been 3.7 and 3.9 and climbing. On MOnday of last week, we called in his 3.9 and asked if Nathan could get a dose of 2.5mg of coumadin (right now his breaking in half a 5mg) and get on a consistant dose of 6.25mg per day as he did much better on a consistant daily dose before. They said no, and to keep taking what he is and do NOT check more than once a week (which when already out of range I thought was kind of not right). Fast foward to this past Friday, and he has another bleed into his elbow with an INR of 4.8 today His clinic is closed today and we are extremely discouraged. He knows all about consistanty of food (although back when he was stable he never noticed much change there). What would you guys do for a dose tonight? He would normally do a 7.5mg today, Mon, Wed and Friday -but he has been steadily climbing on this dose for weeks. Is it that out of the ordinary to request 2.5mg tablets to break in half and want to do 43.75mg for a week/6.25mg per day? The clinic said they never want to do "different doses of tablets". Why do they make different doses then? I also wish we would have tested sooner like he wanted to vs just waiting like the clinic, we could have caught the rise sooner.

 

[Jkm7]

I'm so sorry to hear the problems you and DH are having with dosing and I am about as far from expert at coumadin as it comes. I've only been taking it one month but I have been prescribed a dosage for five days and a higher amount for two days of the week. I have been given Rx for 5 mg and for 2.5 mg tablets. I take 75 mg per week and would be taking quite a lot of pills if only dosed with 2.5 mg tablets.

I know someone more expert than me will be along with good advice.
Good luck.

 

[geebee]

I am so sorry to hear of these problems. It sounds like you need to have a heart to heart with his doctor and coumadin clinic.

If this were me, I would probably take a 1/2 dose today. It sounds to me like Nate may very well be heading back to his original 35mg/week. Stress can cause the INR to go wacky and, if things have settled down a bit, he may not need the higher dose. I would then take 5mg tomorrow, 7.5 on Tuesday and then 5mg for 2 days and test again.

HOWEVER, I am a bit concerned about offering suggestions considering Nate is having problems. Is there any chance of reaching his doctor today?

 

[Natanni]

I am so sorry to hear of these problems. It sounds like you need to have a heart to heart with his doctor and coumadin clinic.

If this were me, I would probably take a 1/2 dose today. It sounds to me like Nate may very well be heading back to his original 35mg/week. Stress can cause the INR to go wacky and, if things have settled down a bit, he may not need the higher dose. I would then take 5mg tomorrow, 7.5 on Tuesday and then 5mg for 2 days and test again.

HOWEVER, I am a bit concerned about offering suggestions considering Nate is having problems. Is there any chance of reaching his doctor today?

I can't reach his doc today, only the on call doc for their clinic and he has only seen Nate once prior, but maybe I could call just to get a dose for tonight.... I was even thinking 2.5mg tonight but then I suppose he will start to ping pong again. What day to re-test? Thursday? I am thinking they will test him at the clinic tomorrow again, but after that?

 

[geebee]

He took 5mg yesterday, correct? His INR could already be starting to come down and you do not want things to go too low. It will be interesting to see what the clinic advises tomorrow.

 

[Natanni]

He took 5mg yesterday, correct? His INR could already be starting to come down and you do not want things to go too low. It will be interesting to see what the clinic advises tomorrow.

5mg yesterday, correct; I am going to find out if he wants me to call the clinic now (bad elbow, high INR and I STILL can't keep him out of the garage ) Will let you know what I find out either way....as always, Thanks Gina

 

[Ross]

Myself I would hold one dose, start back on 1/2 normal tomorrow and cut the over all by 5% and retest in a week, but thats me. What is causing his elbow to bleed?

 

[Natanni]

We don't know why the elbow is bleeding. He leaned on his work bench for awhile and 2 hours later he had the eggplant-all Xrays fine, just an INR of 4.2 (this was the first one). He came home from work on Friday and said his shirt was causing his arm to hurt and could barley get it off, and the same thing as a month ago. Nothing wrong, just a huge hematoma. Checked his INR and presto 4.8-but again he has been climbing for 2 weeks but his clinic didn't want him to adjust or test.

I think he is nervous about skipping tonight. We didn't call the clinic and that makes me nervous Still don't know what we are going to do!

 

[Faye]

I had an elbow bleed a month or so ago. My INR was 4.2 - I was told to hold one dose, take 1/2 dose the next day and return to my normal schedule. They wanted me to hold the dose and reduce the next day's dosage to allow the blood to clot a little better and hopefully stop the bleeding. It worked but I had a bruise on my elbow and down my arm to my wrist for 6 weeks!

They also had me ice the area and then wrap it loosely with an elastic bandage to put a little pressure on it to also help stop the bleed.

Hope this helps.

 

[Natanni]

Thanks Faye-Did you you hurt the elbow or did it just spontaneously start?

 

[aussigal]

Faye's suggestion of ice and a bandage is exactly what I would do. I am also a fan of dividing weekly doses evenly for ease of dosing and hopefully less chance of yo-yo syndrome, so if that means half or quarter tablets then so be it.

As for the current situation I would probably take a half dose (2.5mg) tonight and resume the regular schedule tomorrow and retest in about 4-5 days.

Is there anything-else that may have caused this Elbow trouble?... I wonder if an Ultrasound or an MRI of the elbow would be useful? Has he had previous trouble with the arm like Tennis-elbow?..... just thinking he may have ruptured a tendon or similar...

From what I have learnt here I would have thought his INR would have to be way higher than 4.8 to cause an eggplant sized heamatoma.

Let us know how he gets on.

 

[Natanni]

Faye's suggestion of ice and a bandage is exactly what I would do. I am also a fan of dividing weekly doses evenly for ease of dosing and hopefully less chance of yo-yo syndrome, so if that means half or quarter tablets then so be it.

As for the current situation I would probably take a half dose (2.5mg) tonight and resume the regular schedule tomorrow and retest in about 4-5 days.

Is there anything-else that may have caused this Elbow trouble?... I wonder if an Ultrasound or an MRI of the elbow would be useful? Has he had previous trouble with the arm like Tennis-elbow?..... just thinking he may have ruptured a tendon or similar...

From what I have learnt here I would have thought his INR would have to be way higher than 4.8 to cause an eggplant sized heamatoma.



Let us know how he gets on.

The doctor felt his INR was higher than 4.2 (first one) at the time of injury or event.

I will Toni. Hoping for more details soon. We did ice for 12 hours after this latest episode, and he only now will let a compression stocking rest on it. He has tennis elbow on the other side, and he must have some residual tissue weakness on this side from the first episode. I am hoping they do more than an Xray next tomorrow and we can get him back on track. Wish us luck and thanks guys

 

[dick0236]

I took Vytorin (zetia & simvastatin) for a year or so and my INR moved to the high side, and infrequently, over 4.0. My warfarin dosage was 35mg with some +/- adjustments. In Sept 2007 I discontinued zetia and my INR returned to a stable 2.5-3.5. My dosage has dropped to 32.5mg and has required no adjustment since Jan 2008. I believe that zetia may have contributed to my unstable INR.

I have been on warfarin a long time and have never experienced bruising or a "hematoma" as you have described. I would want my doctor to take a close look as to what is causing the problem.

 

[Karlynn]

I have been on warfarin a long time and have never experienced bruising or a "hematoma" as you have described. I would want my doctor to take a close look as to what is causing the problem.

This was my thought too. Everyone is different. A year ago I took my dog for a walk resulting in him tripped me. I did a beautiful 4 point landing onto the cement sidewalk with one knee getting the brunt of it. After testing that night I found my INR to be over 7 (thanks to New Year's Eve ) and I thought "Oh no, here comes my first big tissue bleed." Surprisingly for me I didn't bruise any more than I normally do, which isn't much more than when I wasn't taking Coumadin.

I'm wondering if he should have his arm scanned to see if there's something going on with the vessels there. I'm really surprised that a 4.8 caused that type of bleed. However, if he has an unknown issue with that arm then the bleed may be drawing attention to it.

Best wishes.

 

[Natanni]

I took Vytorin (zetia & simvastatin) for a year or so and my INR moved to the high side, and infrequently, over 4.0. My warfarin dosage was 35mg with some +/- adjustments. In Sept 2007 I discontinued zetia and my INR returned to a stable 2.5-3.5. My dosage has dropped to 32.5mg and has required no adjustment since Jan 2008. I believe that zetia may have contributed to my unstable INR.

I have been on warfarin a long time and have never experienced bruising or a "hematoma" as you have described. I would want my doctor to take a close look as to what is causing the problem.

I sure hope we don't have any more hematomas, or bruising either. Clearly there must be an underlying problem to my husbands bleed, and it is unfortunate that it has happened twice with INRs higher than 4, but with the 2nd swelling and subsequent hematoma we new his INR was too high and bingo-it was. Today, his doctors are just stumped and we need to just work to get him back undercontrol. Faye, did they ever find the cause of your elbow bruise? My husband has had ONE bruise post AVR, and believe me as a UPS driver, he has been very banged up. I am just being thankful that this is an arm and not something more serious.

He took 5 mg tonight and his doctor is working on get him on some new doses. Thanks for your help guys.

 

[Magic8Ball]

This is just my humble opinion but it sounds like you have more of an idea about controlling your dosing schedule than your clinic does.

Obviously we are not party to all of the goings on but some of the recomendations that you have received re continuing with a dose even though your INR is fairly high sounds borderline dangerous.

I've never felt better, calmer or been so constantly within range since i started home testing and dose adjusting. The first month or two is a little nervous and everyone here was available to second guess my dose's and now i'm fine to do so on my own.

Just something else to consider.