INR 6.5 at lab and 5.2 on InRatio

[Jackie]

I tested on my InRatio this morning and got a 5.0 and 5.2. The lab requested that I go in for a lab test for comparison and it is 6.5. I have never had an INR that high. I am not taking any warfarin tonight, should I hold tomorrow too? The only changes are taking Neurontin and Tylenol with codeine for a couple of weeks. I can hardly walk right now because of pain thought to be sciatica. I am having an MRI Saturday, so maybe I will now more about this awful pain next week. Any suggestions would be greatly appreciated.

 

[catwoman]

Jackie:

What were your previous INRs, dosing, etc.?

If you're having a lot of pain, you're not moving around as much. That could possibly account for some increase in INR due to decrease in activity. But that wouldn't account for the 5.0/5.2/6.5 INRs.

Something else is going on. Just don't know what without more information. Any diarrhea or dehydration lately?

 

[Philip B]

You're High

You're High

Hi Jackie,

Yes, you're high. I've managed to find myself in the low 5's a few times. Even when I'm outside my zone on the high side I've never skipped taking coumadin. I'm not a medical professional, but I usually take a reduced dosage when I'm high.

Others may disagree, but here's my reasoning...Since INR is a result of how your body metabolizes coumadin I figure simply taking less will drop me back into my zone gradually. Skipping a dose would drop me more sharply and I'll find it more difficult get stabilized in my zone where I need to be.

Those of us who home test often remind others that one really can't compare home test results with those done in a lab. Also, remember that the higher you results are the more inaccurate your meter will likely be.

Your home test results indicate that you're in the low 5's. You're high and probably simply need to reduce your dosage to bring yourself back into your zone.

It's also important to remember that for most of us, it takes two or three days for changes in our coumadin dosage to show a significant impact on our INR's.

-Philip

 

[Jackie]

My dose has been 4mg 6 days and 5mg one day a week for at least a year. My INR has raised the last 3 weeks. 2.4, 3.4, 3.6 and this week 5.0 - 5.2 InRatio and 6.5 Lab. My range is 2.5 - 3.5 My activity level has been reduced because of the pain I have been in, but that started the first week of October. I have not had any diarrhea. I may not be drinking as much water as I usually do but I don't think I am dehydrated. Thank you for your replys.

 

[Ross]

Any chance of double dosing and not realizing it?

 

[ALCapshaw2]

Hi Jackie,

Yes, you're high. I've managed to find myself in the low 5's a few times. Even when I'm outside my zone on the high side I've never skipped taking coumadin. I'm not a medical professional, but I usually take a reduced dosage when I'm high.

Others may disagree, but here's my reasoning...Since INR is a result of how your body metabolizes coumadin I figure simply taking less will drop me back into my zone gradually. Skipping a dose would drop me more sharply and I'll find it more difficult get stabilized in my zone where I need to be.

Those of us who home test often remind others that one really can't compare home test results with those done in a lab. Also, remember that the higher you results are the more inaccurate your meter will likely be.

Your home test results indicate that you're in the low 5's. You're high and probably simply need to reduce your dosage to bring yourself back into your zone.

It's also important to remember that for most of us, it takes two or three days for changes in our coumadin dosage to show a significant impact on our INR's.

-Philip

I concur with Philip's comments with a slight caveot.

AL Lodwick's Dosing Guide recommends holding ONE dose for an INR >5.0 and NO Bleeding. In your case, I think holding ONE dose would be appropriate but would NOT hold 2 doses.

Cutting ONE dose in half and retesting in 3-4 days would be a 'conservative' way to 'ease' back into range as Philip indicated. This may require another 'slight' adjustment after your next test.

FWIW, I Never Hold a dose for an INR between 4.0 and 5.0, just take Half a Dose and retest in 4 to 7 days.

The CRNP's at my Anti-Coagulation Clinic all concur that there can be greater 'variation' in higher INR readings. This is a natural result of the mathematical 'curve' that describes the behavior of the reagents used for the test.

'AL C'

 

[Jackie]

Any chance of double dosing and not realizing it?

I really don't think so, I have my little pill box that I fill once a week and I take my warfarin at 6:00 every night by it self. Of course anything is possible. I skipped last nights dose and will probably take half tonite. I know the anticoagulation clinic will want me to skip today but I don't want to fall like a brick and get into a yo yo affect. Thank you for your comments. I just can't imagine what has made my INR go up so high.

 

[Freddie]

Jackie, Tylenol 3 or Tylenol 4 I expect to have codeine in them, so this is what I found:

Although the cause of this potential interaction is not clearly understood, acetaminophen may increase the anticoagulant effect of warfarin. Warfarin is generally used to prevent your blood from "coagulating" or forming blood clots. When acetaminophen and warfarin are used at the same time, your blood may be much less likely to clot and this may increase the risk of excessive bleeding. This risk increases as the dose of acetaminophen is increased. Inform your doctor before taking warfarin with acetaminophen or other over-the-counter pain relievers. Your doctor may want to monitor you closely when therapy with acetaminophen 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.

I had the same problem not to long ago.

 

[Jackie]

Jackie, Tylenol 3 or Tylenol 4 I expect to have codeine in them, so this is what I found:

Although the cause of this potential interaction is not clearly understood, acetaminophen may increase the anticoagulant effect of warfarin. Warfarin is generally used to prevent your blood from "coagulating" or forming blood clots. When acetaminophen and warfarin are used at the same time, your blood may be much less likely to clot and this may increase the risk of excessive bleeding. This risk increases as the dose of acetaminophen is increased. Inform your doctor before taking warfarin with acetaminophen or other over-the-counter pain relievers. Your doctor may want to monitor you closely when therapy with acetaminophen 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.

Thank you Freddie. I was wondering about that but the doctor said I could only take Vicodin or Tylenol with Codeine, The Doctor was filling in for my PCP. I am going to lay off the Tylenol and Codeine. I was taking about 4 a day but now I am only taking one when I have to walk.

 

[catwoman]

Here's something that Al Lodwick -- pharmacist and Certified Anticoagulation Care Provider -- posted about Tylenol & warfarin:

http://www.valvereplacement.com/forums/showthread.php?t=13465&highlight=Tylenol

 

[Freddie]

Don't mean to butt heads with anyone, but there has been new research.
Scroll down the page on this web site - it's what I found when I was taking Tylenol.
http://www.manbir-online.com/warfarin_aceto.htm

 

[Jackie]

Thank you, I will just have to be in pain until they figure out what is causing it. The thing that upsets me the most is, I can't carry my Twin Grandbabies around. I am going up to their place on Tuesday so I can help with Thanksgiving Dinner..................... or take care of the twins............ Of course I would rather take care of Grammy's Angels.

 

[Ross]

Dr. Elaine Hylek was the author of the study that showed that Tylenol and warfarin could interact. I had dinner with her last May. We talked about this again as we had several years ago. It occurs mainly when someone suddenly starts taking more than about 19 extra-strength tablets over the course of a week. They have found the specific enzyme that is involved. Tylenol and warfarin have both been on the market for 50 years or more and there are few reports of deaths. It remains the most effective pain reliever when you are on warfarin. Tylenol is not an anti-inflammatory, just an analgesic. If you do start taking a large amount of Tylenol, it would be wise to have your INR checked. Just beause it raises the INR does not mean that you cannot take the combination. That is an example of a person with a little knowledge making a broad proclamation. It just takes a little warfarin management skill to do it right.

Here is what the Coumadin Yoda has said.

 

[catwoman]

Freddie:

You're not butting heads.

However, what Al Lodwick cited in the link I posted (and that Ross pasted) was a lower number of X strength Tylenol per week than the study you cited. I'll err on the conservative side and figure that about 19 is the magic number.

I took quite a bit of Tylenol last week due to a sinus infection. I didn't bother to test, because I knew it was only short-term. I just didn't see any need to test, adjust, stop Tylenol, retest and readjust for such a short period of time. Just didn't make sense.

If I was needing to stay on it, I would have tested, adjusted and so forth.

 

[njean]

I hope you get back into range soon Jackie! I know how frustrating this is too because I have INR Wars more often than not! But having a home monitor makes it a lot easier to adjust accordingly.

Hope you're all better so that you can spend quality time w/your grand babies next week!

P.S. I also CANNOT take Tylenol w/Codeine. Get a very bad reaction from it.

 

[Bina]

Whatever the cause, I would not hold 2 doses of warfarin for a 5.2.....no way.
A half dose today combined with the Tylenol restriction should put things back in range soon enough.

 

[Jackie]

I just talked with the Anti-coagulation clinic, was told to hold to night and I told her I couldn't do that, I will take half a dose,. She then told me to test again tomorrow, that is too soon right? I will test again on Sunday or Monday. Thanks for all you help.

 

[catwoman]

I just talked with the Anti-coagulation clinic, was told to hold to night and I told her I couldn't do that, I will take half a dose,. She then told me to test again tomorrow, that is too soon right? I will test again on Sunday or Monday. Thanks for all you help.

Testing tomorrow will give you results based on your dosage from 48-72 hours previously.

You would need to retest probably Sunday to get a more accurate picture.

 

[dick0236]

A lab test of 6+ and a home test of 5+ taken at roughly the same time does indicate that your INR is above the high limit. I would have no trouble either holding a dose or halving a dose and rechecking in 4-5 days. Personally, knowing how I react to warfarin, I would hold one dose.

I have been on Tylenol, or its generic, daily(1000mg) for a few years due to spinal disc pain and have seen no noticeable interaction with warfarin.

 

[Ross]

My game plan would be hold one, half the next, then resume normal schedule.