INR of 8.0!

[Emma]

Hi everyone,
I feel awful being absent for so long then popping back to ask for help again so i hope you don't mind. Been so busy with one thing and another that time sorta gets away from me.
So anyway...

Friday night/Saturday morning Chloe gets this sick bug thats been going round and throws up big style for hours! I knew she wouldn't eat the next day - obviously - and knew it would chuck her INR out, but even i wasn't expecting it to be 8 when i tested her Sunday night! I had already tested her Saturday and it had been 2.9. She started eating again Sunday then when i tested in the evening, as i said, it had rocketed to 8! Excellent i thought! So off we went to hospital where they did a venus blood test on her which agreed with coaguchek (YAY for coaguchek!) so they withheld that night's warfarin and kept her in overnight for observation without vit K and luckily she was back down to 5 the next morning and 4 by the evening. Today it's normal at 3.1 again.

A couple of questions though...
Several times i have had to disagree with her doctors about how much warfarin she should have when her levels go off on one - and i've always been right. For example, when her blood went back down to 4 on monday, the doctor only wanted her to take 1.5mg of warfarin as opposed to her normal dose of 3, even though she had missed a dose the day before and so had no warfarin in her. I disagreed and went with mummy instinct (and experience of Chloe on warfarin) and gave her 2.5 and her INR is now perfect at 3.1 (YAY me!).
Question is, is it normal to be as sensitive to warfarin dose changes as Chloe is??
Meaning she can drop and increase by several figures in just 24 hours. The doctors say she's unusual in that sense although lucky as it's quick and easy to sort her INR out when it goes wrong. But i often end up having to argue to get them to believe me. Surely they should be used to it?? Once they withheld a dose when her INR was 5.6 and she dropped to 1.8 the next day (both venus bloods) and ended up on heparin to bring it back up! This was in the early days of her MVR and was one of the incidents that made me take more notice of dosage and Chloe's sensitivity to this drug.


The other question is much less long winded.
When Chloe was sick, what was it that made the INR increase so much?? The actual throwing up? the not eating? not drinking much? or a combination??? Just curious as how to attempt to avoid it in future if possible as, apart from a lack of appetitie, she wasn't ill in herself at all - except during the 4 hours she was physically being sick.


Thanks for listening (if you got this far - well done!)

Emma
xxx

 

[catwoman]

Emma:

I'm sure that Al Lodwick will join in here to correct me if I'm wrong, but seems I've read that the GI tract produces vitamin K. Let something interfere with that production, and the INR will increase. I've read that diarrhea will increase the INR, don't know about other GI upset.
So perhaps the 8.0 was due to that??

 

[ALCapshaw2]

Hello Emma,

That's quite an INR ride!

Vomiting can cause dehydration which can affect INR and electrolyte levels if it continues in high volume. It's probably a good idea to see her doctor or go to the ER where they can give her IV fluids / electrolytes to restabilize her (as well as drugs to settle her stomach).

It sounds like you will want to keep an eye on the Doc's when it comes to dosing though!

Keep up the good work.

'AL'

 

[Guest]

Emma,

Chloe sounds like a pretty normal kid to me. They get very sick very fast and then recover just as fast.

Most docs will only see 1 or 2 kids at most on warfarin during their career. So they have little experience in dosing them. You have the experience with Chloe and the CoaguChek to back up what you do. You have to be the expert in this case.

Vomiting almost always results in a rise in the INR. The worst case is when the warfarin is taken and absorbed but everything else is vomited. Marsha and Al C are on target with their comments. There are bacteria in the GI tract that produce vitamin K. Vomiting can cause them to be expelled. Then without the vitamin K from food, she is set for a roller coaster INR ride. One way to replenish them is yogurt with active cultures of Lactobacillus acidophilus. (Pills work too).

As you have noticed, too, an INR of 8 or so is usually no big deal if it is only at that range for a day or so. I'm glad that they did not give her vitamin K since she was not bleeding. That could have put her at risk of clotting for up to two weeks.

You have also found out that you can manage her as well as the random choice of who you get at the ER.

Today I saw the 6 year old girl that I have been managing warfarin for since she was six months old. In her case, she is just about to the point where she could do a better job than her mother.