INR is all over the map...?

[bugchucker]

Hi folks. I'm 4 weeks post op yesterday. I opted for a tissue valve as I also have Crohn's Disease. My doc wants me on coumadin for 3 months to help the healing and reduce stress on my heart. I had a hard time getting to 2.5. I have a lab within walking distance and have been getting checked weekly. The first week I bumped up to 4, then 3.5 and just got checked today and I'm at 4.7?!? I have 7.5 mg tablets, they had me at 7.5 mg/day 3 days/week and 3.75 mg 4 days/week. I did not read the "read me 1st" post and did as I was told by the releasing nurse...e.g. no dark leafy greens, etc. They are going to hold me tonight and possibly tomorrow. My question is should I self medicate, meaning eat foods with Vitamin K to help bring me back down? I'm bruising VERY easily. Thanks in advance!

I'm taking 4.8g (yes grams!) of Lialda (its a anti-inflamatory).
25 mg Metoprolol twice daily
325 mg Aspirin/day

 

[Karlynn]

Eat what you normally eat. Dark leafy greens, if they had an effect, would be to lower your INR, not raise it. Our mantra is "Dose the diet, don't diet the dose"

I wouldn't let them hold you tomorrow night. You'll go low, and end up with a bouncing INR.

Are you holding your 7.5 or 3.75 dose tonight? This will make a difference on what you weekly dose calculation will be.

IF it were me - I'd just reduce my dose by 10% and see what happens. That would be (if you didn't hold a dose) going to 7.5 2/days, and 3.75 5/days = 33.75 week.

Any dosage adjustments should be made by looking at the weekly total and increasing or decreasing that total dose by X %. (guidelines are 10- 20%).

There are just thoughts from a long-time Coumadin user and self tester/doser. They aren't a medical opinion

 

[Bina]

Phil, if you find that you are bruising more easily, the additional 325mg of Aspirin is probably the culprit.

 

[catwoman]

Phil, if you find that you are bruising more easily, the additional 325mg of Aspirin is probably the culprit.

Amen!
My former cardio had me on 81mg of aspirin and I was bruising pretty badly, so I dropped it. The bruising stopped.

 

[Guest]

I'm 4 weeks post op yesterday. I opted for a tissue valve as I also have Crohn's Disease. My doc wants me on coumadin for 3 months to help the healing and reduce stress on my heart. The first week I bumped up to 4, then 3.5 and just got checked today and I'm at 4.7?!? I have 7.5 mg tablets, they had me at 7.5 mg/day 3 days/week and 3.75 mg 4 days/week. My question is should I self medicate, meaning eat foods with Vitamin K to help bring me back down? I'm bruising VERY easily. Thanks in advance!

I'm taking 4.8g (yes grams!) of Lialda (its a anti-inflamatory).
25 mg Metoprolol twice daily
325 mg Aspirin/day

Karlynn is correct, your total weekly dose should be reduced by 10%. I'm confused as to why they have you take 7.5 for 3 days, then 3.75 for 4. If they draw your blood 2 days after a 7.5 dose, and it's also after a 3 day stint of 7.5 that may be what's driving it high.

I would ask for a more level dosing schedule, such as what Karlynn has suggested. My current dosing is 5 mg 5 days a week, 7.5 on Wed and Saturday. 40 mg total, I've been stable for well over a year.

The aspirin effects platelets so increased bruising should be expected. My hematologist said that aspirin puts your platelets to sleep for 10 days, add coumadin which effects your clotting ability, bruises may increase.

My sister has crohn's, she had surgery this past year, she took pentasa for over a year prior to surgery, http://www.rxlist.com/pentasa-drug.htm, have you tried that medication? She also was put on prednisone to control the inflammation. Your crohn's may effect your absorbtion of coumadin, thereby effecting how much you'll need to stay in range.

I hope this helps.

 

[bugchucker]

Much appreciated guidance! I will try reducing by the week instead of the day. Is it ok to stop the Aspirin without consulting my cardio? I call his office today and no one called me back...I just changed cardios due to a lack of responsiveness...UGG.

 

[ALCapshaw2]

Why so much anti-inflamatory medication?
(Is it the Crone's disease?)

I HATE it when I see / hear of an anticoagulation manager trying to maintain an intermediate Dosing Level by using a Large Dose Tablet and splitting it for alternate days.

Your weekly total comes to 37.5 mg.
That could more easily be maintained with
5mg tablets taken as

5..5..5..(7.5)..5..5..5 with MUCH LESS day-to-day variation

If you also had 1 mg tablets, you could smooth that even more, not to mention make small adjustments more readily.

 

[Ross]

Why so much anti-inflamatory medication?
(Is it the Crone's disease?)

I HATE it when I see / hear of an anticoagulation manager trying to maintain an intermediate Dosing Level by using a Large Dose Tablet and splitting it for alternate days.

Your weekly total comes to 37.5 mg.
That could more easily be maintained with
5mg tablets taken as

5..5..5..(7.5)..5..5..5 with MUCH LESS day-to-day variation

If you also had 1 mg tablets, you could smooth that even more, not to mention make small adjustments more readily.

Agreed! Someone doesn't get the picture at the clinic. You won't become stable being dosed like you are now. The idea is to have about the same amount of Warfarin in your system as evenly as possible and they sure aren't doing that.

Never ever fall for that, "Don't eat greens B.S." Eat the way you always have, do not deviate from that model. Make them dose the diet you eat.

 

[bugchucker]

Yes, the Lialda (anti inflamitory) is for the crohn's...funny thing is I was medication free except immodium until the Warfarin, it is creating havoc with my bowels. I went for another blood test this AM, should have the results this afternoon...To top it off my cardio's nurse still has not called back. I really don't want to keep bouncing from cardio to cardio, but no one seems interested in my progress and treatment. Thanks all! Assuming they call me back I will ask for a lower dosage.

 

[Ross]

Phil with Crohns, it may be a real hard deal to keep you stable. It just depends on how many attacks you have and how much good bacteria leaves your system prematurally. It's not impossible, but it is difficult. I do think that your clinic needs to do a better job at keeping the dose more even throughout the week.

This link may be of some interest to you:

http://warfarinfo.com/crohns.htm

 

[bugchucker]

Update. Yesterday my INR was 3.5 and they held me a 2nd day, this doesn't seem to make sense according to the posts above. I was tested again today, but don't have my results yet. Should I seek a new clinic and cardio or just be more firm with them?

I had a flex sigmoidoscopy (to look at the lower 45 cm of my colon), I'm starting to flare and becoming anemic. Would Iron supplements interfere with the Warfarin?

Thanks for all the help and support!
Phil

 

[Bina]

Your INR is on it's way down and they ask you to hold another dose.....that is not right.
Also, checking and adjusting every day at this point in time is just going to make the INR bounce around.
I would only test again after a few days, let your level stabilize.

 

[Guest]

I checked the drug interaction site DRUG DIGEST


Check Interactions | DrugDigest

No interactions were found for the drugs you selected.
You searched for interactions between the following drugs and herbs:

Coumadin Tablets
Iron Tablets (Ferrous Gluconate)
Iron Tablets (Ferrous Sulfate)

The effects of coumadin you take today won't show up until 2 to 3 days later so checking your INR every day won't give the true INR. As Bina said, they'll have you all over the place.

 

[bugchucker]

Thanks for checking, guess I could have checked myself.

 

[Ross]

It's becoming more apparent that your clinic is responible for your INR being all over the map. They seem to be clueless, which around here, is nothing new. We deal with it every single day in here. At some point, you have to simply take the bull by the horns and work this out yourself. I shouldn't tell anyone to disregard their instructions, but when they prove incapable of being able to dose correctly, I have no problem telling someone to do just that.

By the way, I'm taking ferrous sulfate right now, twice a day for anemia from my dental surgery and it does not interfere with coumadin. It can scare you during a bowel movement though. Makes it a dark green, almost black, which could mistakenly be taken for bleeding.