INR above 8.0????

[watson524]

So my mother who's been on coumadin and pretty darn stable for 35 years just went for her finger stick (still working on the home kit) and it read 8 (which is the max of the machine apparently). Her caregiver was with her so they called me. She retested in another finger, same. They're going to do a blood draw with some additional tests and see what's what but holy heck!! The Saturday before Thanksgiving she ended up in the hospital with a UTI and they had her on an antibiotic (ceftriaxone via IV and then another one orally for a few days total 8 days) and they were monitoring the INR with that (it bounced a bit between 1.8 and 3.5. After 9 days in the hospital she went to a skilled facility for some rehab the Monday after Thanksgiving and came home a week ago Friday. Since the Monday after Thanksgiving she hasn't been on an antibiotic and the skilled facility tested her INR 3x in 10 days. 11/29 it was 2.55 (perfect!), 12/2 was 3.28 (high but not scary, they adjusted her dose from the normal 5mg to 4.5/4 on alternating days. 12/8 it was 1.64 so they put her back to her original 5mg / day which she's been on for over a year and always in range. She goes today and gets that result of 8!!! Her diet has been about the same, she eats the same amount of greens each week, nothing else changed but she did get a head cold and due to her neurological disease, she can't make herself blow her nose or cough. Nurse has us managing with Mucinex but the one with only the 2 ingredient which the home health nurse and the anti-coag clinic pharmacist said shouldn't be an issue (and she's taken it before).

Anyone ever had this high of a reading before? Obviously we're holding the coumadin tonite and we'll see what the blood work says but wow..... The pharmacist even said you'd expect with an INR of 8 for the stick to bleed more and it really didn't so she was perplexed too

 

[pellicle]

Hi

myself no, but have read of it (posted a link recently)

In and of itself its not a cause for a problem, but you need to be VERY careful till it comes down.

Consider (strongly) taking some Vitamin K tablets your pharmacy should be able to supply them.

Alternatively juice about 500g of fresh spinach with some yoghurt and drink that ... you may need a second dose.

The Vitamin K will restore coagulation relatively swiftly but will not change the amount of warfarin in the blood, so you'll need to lower the doses. I suggest hold the dose (as you've outlined). From there revert to about half the dose on the next day and test again. You want to try to not over correct this and end up taking a dive to 1

I'll read your post more carefully and get back in a tic (should you be checking this often)

 

[pellicle]

Yes, as I suspected

https://www.ncbi.nlm.nih.gov/pubmed/25092605

CONCLUSION: Ceftriaxone interacts with warfarin to increase a patient's INR value more than other commonly administered antibiotics for UTI treatment. Other antibiotics should be preferred for UTI treatment in patients on warfarin.

another medical specialists failure

is she still on that antibiotic?

Also, I don't think the stick bleed is a good indicator ... I've had INR = 1.8 bleed like a stuck pig for minutes but 3.0 not ... so go figga there.

Bottom line for me is that the INR reading by the machine is your go to number ... if its a coagucheck then it could be that her INR is a bit lower, as they tend to read higher in error as the INR is higher ... which is good because it makes you more careful than perhaps you would be.

http://circ.ahajournals.org/content/125/23/2944.full

[FONT=&quot]For most warfarin-treated patients who are not bleeding and whose INR is >4.0, oral vitamin K (in doses between 1 and 2.5 mg) will lower the INR to between 1.8 and 4.0 within 24 hours[/FONT]

 

[Superman]

Is she drinking cranberry juice to stave off another UTI?

Thanksgiving was almost a month ago (November 24th), pellicle. If I'm reading right - she's been off the antibiotic for a bit.

 

[watson524]

Yep she's been off the abx well over 2 weeks now. She drinks a juice glass of either cranberry or tomato juice every morning and has for many years so there's nothing different there (and as an aside, I wouldn't let her take her normal cranberry juice to stave off the UTIs since there's so stinkin' much sugar in those juices it becomes useless, I'd have her take cranberry pills, but that's another story). In the few minutes since I've posted I've done some reading and I'm wondering if her CHF (from her MV insufficiency) is getting worse. Since she's been home her legs have swelled some but we manage that with lasix as we always have (alternating 20 and 40mg / day). The hospital and skilled place didn't give her any lasix which in the hospital was fine since the "pumpers" were on her legs but in the skilled place, they don't "like" to use lasix.... yeah, inconvenience to the staff for how much people pee) and I noticed things getting puffy so we started back on lasix when she came home but of course it's always a juggling game with how much she drinks of water daily (about 40oz which really isn't a lot) plus her juice and SOMETIMES 1 can of ginger ale during the day. So we juggle that there. Her breathing even with the cold hasn't been bad. O2 was 86 at one point when home nurse was here but she sort of coughed and moved some mucus and it immediately went up to 95 and the nurses and doctors have all said there's no lung sounds to make us think fluid was backing up that much. It is about the only thing I can think of (other than a faulty test machine which I suppose COULD happen) I can think of

 

[watson524]

And re: the abx they used, I questioned the hospital pharmacist on the floor about it since I knew that to be one that affects INR (like doxy) and she's like oh that's not one we are generally concerned about. Um ok... what do I know, I'm a database administrator.... but since they were testing her INR so often in the hospital, I wasn't TOO concerned.

 

[pellicle]

thanks for the updates on dates (I'm clueless on that sort of thing)

Good point on the Cranberry Juice Superman ... I'd wonder if perhaps just her metabolism has changed (or maybe she's had more?)

Dunno ... either way as I suggested:

• be careful, do not have a fall
• take the Vitamin K as in the above guideline
• test again in 24 hours (yes, it can change that rapidly) as strip costs are negligible really
• take care to not over steer dose corrections (and plummet the INR down)

Cranberry juice is a known interaction with warfarin (and some other drugs too btw) but ginger beer isn't ;-)

I would doubt its a faulty machine, but the batch of strips could be sus ... get the person to test themselves ... should be close to 1 ... that will at least put data on the table there.

 

[watson524]

Pellicle - My guess is since you translated ginger ale to ginger beer you're in the UK This isn't ale like you'd think of it, it's a soda/pop. She actually doesn't drink alcohol at all so at least we don't have that factor to content with too. We don't have a home meter (yet) so the anti-coag lab did a full blood draw and will get back to me with results tomorrow on a go forward plan (i.e. hold another day, come in for a test Thursday, etc). Between her neurological disease (Progressive Supranuclear Palsy) and the heart thing.... juggling a lot. She uses a wheel chair all the time as she can't walk much because of the neuro disease so risk of falling is pretty darn low thankfully.

 

[pellicle]

also, I noted that LASIX is associated with a reduced INR, so if her dose has been adjusted to be OK with the LASIX then taking her off that may elevate INR ...

https://www.ncbi.nlm.nih.gov/pubmed/9200780

The initiation of furosemide dosing in a patient receiving a stable dose of warfarin was associated with an 28% decrease in the international normalized ration (INR). Using normal volunteers, two previous controlled studies of an interaction between warfarin and chlorthalidone, and between warfarin and spironolactone, assert that volume depletion produced by forced diuresis results in the inhibition of warfarin's hypoprothrombinemia. Consistent with this hypothesis, the authors found that their patient's hematocrit (believed to reflect hydration status) correlated with the INR: r2 = 0.78, p < 0.05. This case provides further evidence suggesting that acute diuresis can decrease the hypoprothrombinemic effect of warfarin.

 

[dick0236]

A couple years ago I also took Mucinex for a week or so when I had a bad cold....and it did cause my INR to increase from about 3 to a little above 4. I stopped the Mucines and my INR returned to the 3s. I suspect the anti-biotics plus cold remedies plus the cold virus itself has created a "perfect storm" with the INR.

 

[pellicle]

Hi

Pellicle - My guess is since you translated ginger ale to ginger beer you're in the UK .

no, I'm in Finland ... but I'm an Australian and so we tend to follow some UK conventions of names In Australia Ginger Beer is mostly non-alcoholic either way I don't think either of the variants of that soft drink will have any influence.

 

[Superman]

Cranberry juice is also perceived to prevent UTI's - so that's why I'm wondering if she increased it all. I was on a cranberry juice kick one time. Really liked the stuff. Don't know why. Didn't even mix it with anything fun. Anyway - had blood in my urine (brown) and went straight to the lab and tested at over 10. Haven't had much more than a sip since. No home testing back then.

Lab didn't even believe at the time that cranberry was an issue. All I know is drinking it, INR went way up, and after I stopped, it came down. Maybe not for all - but it is for me.

Blinded by information, can't even pay attention to what's in front of them sometimes.

 

[pellicle]

...Blinded by information, can't even pay attention to what's in front of them sometimes.

its an issue for all of us ... I wonder if AI Expert systems will sort this out? Some very encouraging work emerging with histology examinations by AI ...

 

[watson524]

Superman - nope, one juice glass worth / day. She can't even reach the glasses let alone pour anything for herself

pellicle and dick0236 thanks for the added info. That's very interesting about the lasix too. She's been back on it for about a week but still could be "ramping up" in her system I suppose. Plus like dick said, the cold and mucinex and all.

I'll report back tomorrow once I get the vein draw numbers.

 

[pellicle]

I'll report back tomorrow once I get the vein draw numbers.

Thanks .. hope all goes well

 

[watson524]

Just heard from the lab and the results got posted to the portal. Vein draw was 8.22 on the INR so it's definitely not an issue with the strips. on the CBC, everything is in the normal range sans the WBC which is only slightly high and expected given the cold I think. They also did a CMP to look at liver function and basically everything is normal there. Glucose was a touch high (158) but she wasn't fasting since there was no expectation of this being done. Bilirubin is a touch high but that's always been like that (and runs in the family). So we are all scratching our heads. They want her to hold it tonite, tomorrow and Thursday and come in Friday afternoon for a test again.

Could dehydration cause this at all? Last nurse visit she mentioned she may be slightly dehydrated because her pulse was high (105) and bp was somewhat low on the top number (90/68). But she is drinking a decent amount (for her) and we juggle fluid intake with 20 or 40mg / lasix most days. She has some fluid in her legs but it's been worse and hasn't had any affect.

 

[watson524]

Just noticed her anion gap is "high" at 18 (vs the normal range of 7 to 15). All test in the past had been 7 or 8 so I'm looking into what that means since I know Potassium is one of the "unmeasured ions" that's part of the gap.

 

[pellicle]

Hi

so did you impliment the things I suggested?

Chasing the cause is one thing, treating the high INR is another (more pressing urgency).

I had little doubt that the INR was as it was read (now verified) and that's why I wrote what I wrote.

As to dehydration, not that I've ever heard.

 

[pellicle]

also, let me verify my understanding:

24 Nov = thanksgiving reading??
25
26
26
28
29 Nov it was 2.55 (perfect!),
30
1 Dec
2 Dec was 3.28 (...they adjusted her dose down)
6 days pass (hardly precautionary)
8th Dec it was 1.64 so they put her back to her original 5mg / day
11 days pass with no verification reads?
19th INR 8

I would not be comfortable with that management strategy nor would I be comfortable after seeing an irregular patch leaving it 11 more days to see what was going on.

When someone is regular every reading it may be acceptable (but is not in my view) to reduce readings to fortnightly, but when you have just seen an event you should monitor it. Because by definition you are out of "smooth sailing" waters.

I still suggests the regime I first posted, give vitamin K from: http://circ.ahajournals.org/content/125/23/2944.full

For most warfarin-treated patients who are not bleeding and whose INR is >4.0, oral vitamin K (in doses between 1 and 2.5 mg) will lower the INR to between 1.8 and 4.0 within 24 hours

then as per my post here:
http://www.valvereplacement.org/foru...215#post871215

be careful, do not have a fall

• take the Vitamin K as in the above guideline
• test again in 24 hours (yes, it can change that rapidly) as strip costs are negligible really
• take care to not over steer dose corrections (and plummet the INR down)

also, as I mentioned earlier:


The Vitamin K will restore coagulation relatively swiftly but will not change the amount of warfarin in the blood, so you'll need to lower the doses. I suggest hold the dose (as you've outlined). From there revert to about half the dose on the next day and test again. You want to try to not over correct this and end up taking a dive to 1


feel free to PM me and we can discuss via skype if you wish.

 

[watson524]

We didn't do the vitamin K tablets (yet) because I was waiting to hear the actual reading from the blood draw tho I did have her eat green beans last nite to hopefully start to get things notched down. Here are the results recently (11/19 - 11/28 was hospital, 11/29 - 12/8 was skilled facility, she would have had an appointment 12/16 for a test but because she went home with home health, the skilled facility automatically cancelled it without asking me but home health so there's no reason for us to do a blood draw on her since she's a hard stick, go to the clinic and they couldn't get back in until yesterday).

Ironically, I just got the patient information packet from Roche in the mail yesterday so we can get her set up with a home meter which means I can control this vs waiting for doctors and nonsense like that. I am still researching this anion problem that coincidentally (?) just also show up in recent labs and didn't have any issue before.

19-Nov	2.6
20-Nov	2.87
21-Nov	3.63
22-Nov	3.04
23-Nov	2.35
24-Nov	2.3
25-Nov	1.99
26-Nov	1.82
27-Nov	2.11
28-Nov	2.4
29-Nov	2.55
2-Dec	3.28
8-Dec	1.64
19-Dec	8.2