INR range for person on ACT because of a fib, all native valves

[watson524]

Hi all,

I'm wondering if anyone here is on ACT because of a fib only, and not because they've had a valve replaced? My mom has been on ACT for almost 30 years and is very steady in dosing (4mg / day of coumadin). She has not had valve surgery so all valves are native.

The reason I ask is because during blood work yesterday at CCF, her INR reading came up as 1.6 and I say that's too low. I asked her what range her GP (who manages her dosing and is NOT in favor of home monitoring gggrrr.....) keeps her in and she said it's always been around there. For a fib only ACTers, what ranges do you have? I would think 2.0 - 3.0 would be more appropriate and the online dosing calculator says that day 4 and 6 should be 5mg and 4mg the rest of the time to get into that range.

What do you guys think?

thanks!

 

[Freddie]

Hi waston, after doing some Google searches, I believe you to be correct in thinking that your mothers range should be 2.0 to 3.0.

Maybe it's time for you to step in and ask some questions to her doctor.

 

[catwoman]

Freddie's correct -- 2.0-3.0 is the standard for a-fib.

Sounds like her GP may be more concerned about a bleed than her having a stroke as result of the a-fib. Has she ever had a stroke due to the a-fib or any other cause?

 

[ALCapshaw2]

The Risk of Clot formation rises rapidly for an INR below 2.0 so I agree that a Target Range of 2.0 to 3.0 sounds more appropriate but admit that I have not heard of a specific target range for AFIB patients only. I will try to remember to ask my Coumadin Clinic Nurse at my next appointment. FYI, AFIB is the Primary reason that patients are placed on AntiCoagulation Therapy so surely there are practicioneers who will know the answer to your question!

'AL Capshaw'

 

[catwoman]

The Risk of Clot formation rises rapidly for an INR below 2.0 so I agree that a Target Range of 2.0 to 3.0 sounds more appropriate but admit that I have not heard of a specific target range for AFIB patients only. I will try to remember to ask my Coumadin Clinic Nurse at my next appointment. FYI, AFIB is the Primary reason that patients are placed on AntiCoagulation Therapy so surely there are practicioneers who will know the answer to your question!

'AL Capshaw'

Prescribing information for Coumadin brand of warfarin sodium indicates INR range of 2.0-3.0 for a-fib.
http://packageinserts.bms.com/pi/pi_coumadin.pdf

 

[watson524]

Nope, she's never had a stroke or any other bleed event all the time she's been on coumadin or before that.

 

[watson524]

Thanks Marsha! I am going to print out that file and show it to her. I did ask her this morning to please get a least the last years worth of INR readings (the hospital she gets the blood draw reports to the doctor, then the doctor calls her and says "stay the same" but we never hear her INR number. I told her that I was investigating but I think her INR should be a bit higher. She does bruise easily like on the back of her hand if she whacks it or something so maybe he's concerned about that but below 2.0 just makes me nervous.... And based on the calculated, it looks like 2 more mg / week would bump her into the right range, if 2 - 3 is what it's determined to be.

In reading this:
Atrial Fibrillation: Five clinical trials evaluated the effects of warfarin in patients with non-valvular atrial fibrillation (AF). Meta-analysis findings of these studies revealed that the effects of warfarin in reducing thromboembolic events including stroke were similar at either moderately high INR (2.0-4.5) or low INR (1.4-3.0). There was a significant reduction in minor bleeds at the low INR. There are no adequate and well-controlled studies in populations with atrial fibrillation and valvular heart disease. Similar data from clinical studies in valvular atrial fibrillation patients are not available. The trials in non-valvular atrial fibrillation support the 7th ACCP recommendation that an INR of 2.0 to 3.0 be used for warfarin therapy in appropriate AF patients.

It sort of sounds like there's not an appreciable differences for reduction of stroke with a range of 2.0 - 4.5 vs 1.4 - 3 which is interesting. But it's that last sentence I need to get in front of her.

 

[watson524]

Thanks Al, if you do happen to find anything else out, please let me know. In the meantime, I'm going to see what I can do about helping mom get her last few months of INR readings and seeing what's what. I know in December at CCF it was 1.2 but she was having a cath so they had her off it for 5 days before so the 1.2 made sense. This time, no cath so no reason to hold coumadin so when I saw the 1.6 I was like ????????

 

[catwoman]

Is your mom also taking aspirin or Plavix? If so, that would increase bruising.

 

[watson524]

Nope, no aspirin or Plavix. The only meds she taks are the Coumadin, Atenolol, Lisinopril, a daily multi vitamin and daily calcium + vitamin D.

 

[watson524]

My mom talked to her GPs office today and apparently she's always been in the 1.5 - 1.8 range. She explained to them why she was asking and said the patient insert info says 2.0 - 3.0 and she didn't think her potential surgeon at CCF should have had to ask if she was on Coumadin but after seeing the 1.6 and me explaining my thoughts, she understood WHY he had to ask that. The nurse at the office told her they keep all their folks in about that range and she said she wanted to talk to the doc. She did say that she has a 1mg pill Rx too as sometimes he has had her take an extra 1mg / day for 2 weeks and retest before going back to 4mg / day but I said that's nice but it's only for that one week and that won't keep your INR up long term which she gets. So anyway, she has an appointment for the 28th of this month with the GP (and a follow up with her local cardio on 7/21 to discuss the latest CCF trip). She's not due for her next INR testing until the first week of August but she's going to go the day before meeting with the GP anyway so he has the most recent reading and it can be discussed. I told her he may have a good reason for keeping her in that range but I want to hear it. She always mentions about how when she gets a cut or something she doesn't bleed much and was always surprised by that.... yeah now I know why. I know it's worked well for 30 years but I was 5 when this started and didn't know much (LOL!). Now I do, mainly due to the great folks here, so I am asking a LOT more questions.

 

[catwoman]

Does her cardio's practice have a Coumadin clinic? If your signature line is about your mom's MV problems and not yours, she really does need to be in the 2.0-3.0 range. The a-fib coupled with MV problems could throw clots. The range specified for a-fib is 2.0-3.0, but what I've seen listed is a target of 2.5 -- midrange.
My range is 2.5-3.5 for a mechanical MV. I prefer it to be midrange, 3.0-3.5.
And like your mom, I really don't bleed that much. You just apply pressure and it generally will stop. Put a bandage on it so you won't inadvertently stain your clothes (or in my case, a beautifully groomed all-white Persian cat).

 

[watson524]

Nope, he doesn't have a coumadin clinic. We don't have any in the area really. I investigated that when I wanted her to try to get a finger stick vs a vein draw. There is ONE but you have to be on their medical plan (Geisinger). She goes to a local hospital for a lab blood draw and they call her doctor with the results.

 

[catwoman]

Nope, he doesn't have a coumadin clinic. We don't have any in the area really. I investigated that when I wanted her to try to get a finger stick vs a vein draw. There is ONE but you have to be on their medical plan (Geisinger). She goes to a local hospital for a lab blood draw and they call her doctor with the results.

I'm sure you're already aware of it, but if your mom is on Medicare, she qualifies for a home tester -- if her Dr. will sign the paperwork.

 

[watson524]

Yep.... we looked into that before when she was sort of interested in looking into it (she wasn't convinced she wanted to do home testing and ultimately it has to be her choice) but when she asked her GP about it (and I was sitting there) he said no way would he approve of that. "Coumadin is a very dangerous drug if not properly monitored and you can have serious complications".....

Yeah got it, but frankly, I think her and I can do a better job of keeping her at an appropriate range than the 1.6 he seems to think is ok. Will be interesting when we talk to him directly on the 28th.

 

[watson524]

Well we met with the GP today. I sat patiently and didn't interrupt (or blow a gasket) so I'm impressed with myself

Anyway, she asked him about it. He told her the range he'd like her in is 2.0 - 3.0 (and generally 2.5 - 3.5 if the valve was replaced). She said ok when I called your nurse said 1.5 - 1.8 or so. He said that's too tight anyway AND too low so I'll have a talk with her as that's not correct info. Anyway, she was tested last week, 1.6 again (same as 7/8/11 at CCF). So they both told me that he told her to double the dose for 2 days and retest in 3 weeks. Let me get this straight. She takes 4mg / day. After the 1.6 reading you want her at 8mg for 2 days, then back to 4mg / day for the balance of the 3 weeks and retest??? I refrained from asking what in the %$!! he thought that would do other than start a potential roller coaster. He said if it's still low, they may have to increase the dosage. I bit my tongue from saying "yeah, 4mg / day except days 4 and 6 where it should be 5mg!!" but when she was checking out, I mentioned this all to her. She said she does have 1mg pills in addition to the 4mg ones. I at least have her thinking. I think she'll see what the test comes back with in 1.5 - 2 weeks to see what he does then and then we'll be revisiting. I really just wanted to be like, just let me handle the dosing because clearly I can do a better job. BAH!!

The GOOD thing is I heard from his mouth that her range should be 2.0 - 3.0 (though he said he prefers the lower end of that... ok, I'll take that).

 

[Protimenow]

So -- let me get this straight -- Coumadin is a dangerous drug and should be carefully monitored. So this doctor changes her dose for TWO DAYS and wants to retest in 3 WEEKS? This is careful monitoring? Does he expect the dose increase to show up in her INR 3 WEEKS from now?

If your doctor believes in careful monitoring, it seems like you've got to find someone else to do it -- or do it yourself. What the doctor suggested (if this is really what he suggested) doesn't make a whole lot of sense. This sounds like a great reason to get your own meter, do your own testing, and take control of the INR yourself. (Armed with information on this forum, and realizing that kneejerk reactions don't help establish stable INRs, lots of people are able to manage their INRs - even though they're not as 'smart' as doctors (right))

 

[watson524]

You have it right. AND he doesn't believe in home monitoring since that has been raised before when I had her at least thinking about it. AND there's no way she'd change doctors over this.... I just don't get it. If they take her off coumadin only 5 days before surgery, how does he think 8mg for 2 days at day 1 is going to have any affect for testing at day 21?? (And yes, take a double dose for the next two days is exactly what I heard from his mouth). I am totally certain I could do a better job of managing this than he could at this point.

 

[Jason]

My dad is an A-fib-er on warfarin, and he has a range of 2-3. His GP manages his dose, and I am trying to get him on home monitoring. The doc changes his dose fairly frequently, and has him skip doses if his INR is too high, etc. All things that point to home monitoring being more successful, I think.

 

[Protimenow]

Jason:

There are research papers that bear out your assumption. People who home test do better at staying in range than those who do lab testing. It sounds like your dad's doctor is creating an INR roller coaster that doesn't show up because testing isn't frequent enough to reveal this. Home monitoring sounds like a definite plus for your dad so he can stay in range once he is actually IN range. Skipping doses for someone on A-fib isn't a good idea.