INR Ranges?

[Natanni]

Hey Guys!

The other thread about missed doses got me wondering about Nathan's target range of 2.5 to 3.5--most others with AVR have targets of 2 to 3, unless risk factors, such as stroke? Now I am worried that Nathan has some risk factor out there unknown to us....he is a young guy with an extremely active lifestyle...can anyone clarify exactly how a doc works up a target range?

 

[Ross]

Not really. Some Doctors like to use the higher range regardless. I sure don't think it's a bad idea.

 

[Guest]

There is a committee sponsored by the medical journal Chest that meets every 2 or 3 years. They look at studies, case reports etc and assign them rankings of how reliable they seem to be. Then they come to a consensus as to what the recommendations should be. The main ranges for heart valves are aortic 2.0 to 3.0 (but in reality most doctors use 2.5 to 3.5) and mitral 2.5 to 3.5. There is very little practical difference between the two ranges. The doctors can tailor these to individual patients. When they do this, you should have an explanation as to why yours are outside the guidelines. For example, somebody who had a stroke when the INR was 3.2, might benefit from keeping the INR up to as much as 4.0. On the other hand, someone who has had bloody noses to the point of needing transfusions might need the range lowered to 1.5 to 2.5.

It is absolutely totally meaningless to set a range like 2.0 to 2.5 for someone. All this does is assure that you will not be in range very often. I consider a range like this to come only from people who do not understand very much about warfarin. It is hard enough to keep the INR within a range of 1.0 units without making the range narrower.

If I am managing warfarin for someone who has a mechanical valve and they have just had a bleeding ulcer (for example) I might temporarily lower the range on my own for a little while to allow for complete healing, but I always put in the report to the doctor what my line of reasoning is. That way if the doc disagrees with me then they can always change what I have done. It happens maybe once in every 1,000 visits or so.

A speaker at one of our meetings said that she ordered 120 copies of the Chest guidelines for every physician at her hospital. The person who took the order asked what law firm she was with. When she said that she was a physician buying them for other physicians the person taking the order said that she had never sold any to a doctor before!!!

 

[Ross]

A speaker at one of our meetings said that she ordered 120 copies of the Chest guidelines for every physician at her hospital. The person who took the order asked what law firm she was with. When she said that she was a physician buying them for other physicians the person taking the order said that she had never sold any to a doctor before!!!

Al do you think we'll ever see the situation get turned around and have knowledgeable physicians in our lifetimes?

 

[Guest]

The majority will probably not learn it. There are so many other, more interesting things to learn that it grabs few people's attention.

 

[Rich]

Nate and Annie,
I have had my St. Jude mechanical for well over nine years.
My target range has always been 2.5-3.5 and I have had very few problems over the years.

Ross,
I don't think many doctors other than some cardiologists will ever get it.
Like I mentioned a while back, my neighbor's pcp told him to stop his Coumadin for at least five days OR MORE just to have a routine colon check.
I almost went ballistic when I heard that and had a long talk with my neighbor.
I did tell him what I thought about his doctor, I had a name for him but I can't mention that on this forum,it was something like where the sun don't shine!

 

[Ross]

Ross,
I don't think many doctors other than some cardiologists will ever get it.
Like I mentioned a while back, my neighbor's pcp told him to stop his Coumadin for at least five days OR MORE just to have a routine colon check.
I almost went ballistic when I heard that and had a long talk with my neighbor.
I did tell him what I thought about his doctor, I had a name for him but I can't mention that on this forum,it was something like where the sun don't shine!

Painful Rectal Itch?

 

[Rich]

Ross,
I think that describes it perfectly.

 

[Guest]

I just read another interesting facet of proper drug ordering.

Most people can handle four variables when making a decision. Getting the correct medication, in the correct dose, for the correct patient, by the correct route, considering blood level ranges, reducing doses when necessary for reduced kidney function, etc can involve as many as 30 variables.

With this in mind, it is amazing that doctors come as close as they do.

The article was about having physicians use computers to directly enter orders for patients in hospitals. So far the results have been disappointing because nobody has adequately written a program that can handle all of these variables for every drug.