INR testing frequency is to often to much

[warrenr]

Most of you are familiar with the circumstances with my father's stroke.

I had not thought much about it until the other day when I got a lab bill for my father's INR lab test's. The long term care facility is testing his INR 2 times per week. I questioned one of the nurses about it and she said that they test all coumadin patients at least once a week and some 2 times weekly because of INR fluctuations.

Is there any advantage or dissadvantage to testing this often? I can't recall reading any literature that calls for INR testing 2 times weekly. It seems to me that testing this often they never really see the true effect of dose changes and continually are adjusting and chasing there tails.

My father has a St. Jude Mech Mitral Valve, afib, and stroke. Even when his INR is 3.7 the physician will make adjustment's down. It's like they think the world is going to end if someone get's up to 4.0

Any thoughts?

 

[EVELYN]

Hello Warren

I know we test once a week.....almost always on the same day, Thursday. It seems to work best for us. At that point we make any adjustments necessary....usually none. I know it takes 3 days to effect a change, so to me IMHO, twice a week is too much unless there was a hugely high INR. Personally, 3.7 is fine with us. Tyce is supposed to be 2.5-3.5, but we do nothing unless he goes over 4.7ish as far as change in pills. However, if he is on the high side, he drinks lots of V8, eats salads, broccoli, and asparagas and enjoys every morsel.

He has had his very high times...ie., 5.9 or 6.7 or so, and if that occurs we cut back pills by 10% and check in 3 days. Don't know if that's right, but that has always worked for us.

Evelyn

 

[Karlynn]

I test weekly as well, because my INR has never been very stable when testing 1 time a month. It has been at 1 time a week because I can make small adjustments if needed. I test weekly mainly to keep from going too low. Too high doesn't really bother me. It does, however, seem to bother a lot of doctors. With my range of 2.5 - 3.5, I would not be bothered, or really consider it "out of range" to have an INR of 3.7, or even 4.0. I make no changes. If I have seen that my INR had been trending upwards, I may have a V8 or spinach salad, but I usually make no changes.

As, I'm sure you already know, making changes for readings slightly out of range will cause a see-saw affect. But, as you also know too well, doctors are just so unnecessarily fearful of bleeding.

 

[Nancy]

I believe in-house testing is different. Don't know why.

I can tell you that every time Joe has been hospitalized, his INR is tested daily, and after his last hospitalization, he went home with instructions to have it tested daily until it stabilized.

 

[geebee]

Whenever I have been in the hospital, my INR has been tested at least every other day and sometimes every day depending on why I was in.

I think twice a week is probably not too much considering the situation. I would feel much better with this schedule than a home deciding once a month is enough.

 

[tommy]

Changing the Coumadin/Warfarin dose is like steering a boat.

 

[Emma]

We've been told we can test Chloe's INR up to 4-5 weeks apart with our machine as she's so stable but I don't like that, it makes me nervous to leave it that long so I test her every Sunday night before school starts for the week for my own peace of mind

Emma
xxx

 

[terryj]

My husband tests once a month at his PCPs office. If it is a little high or low, but not too out of range for adjusting he retests in 2 weeks. It has only been high or low enough to make adjustments a few times in the past 4 years. Then, he makes the adjustments and retests in 3 days.

 

[jeffp]

Inpatient testing especially when the patient is out of range, is a different beast than testing on maintenance dosage. When someone is low and they are ramping up the dosage, frequent testing is the norm. The idea is to start to pull back a bit as the INR increase rate goes up, trying to no overshoot (by too much). I've cases where PT testing was done in the AM and again in the PM. Often these folks are on heparin and waiting to get INR in range before discontinuing.

 

[warrenr]

Inpatient testing especially when the patient is out of range, is a different beast than testing on maintenance dosage. When someone is low and they are ramping up the dosage, frequent testing is the norm. The idea is to start to pull back a bit as the INR increase rate goes up, trying to no overshoot (by too much). I've cases where PT testing was done in the AM and again in the PM. Often these folks are on heparin and waiting to get INR in range before discontinuing.[/QUOTE

jeffp,
my father is on maintenance, it's just that he happens to be in a long term care facility for the rest of his life. his inr has been fairly stable since his stroke in march 2004. It seems to me that by checking 2 times weekly and continually tweaking his dosage up or down they will never get consistant inr reading. its like they are attempting to keep his inr at an exact level instead of a desired range. could it possibly have something to do with the bottom line($$$$). his desired range is 3.0 - 4.0. if his inr is 3.7 tomorrow they will tweak down the dosage. if the inr is 3.5 3 or 4 days later they tweak it down again. if the next check is 2.8 they tweak it back up. it seems like they are chasing there tails. it is great for the lab and the physician because they keep billing the insurance company.

 

[Mary]

Inpatient testing especially when the patient is out of range, is a different beast than testing on maintenance dosage. When someone is low and they are ramping up the dosage, frequent testing is the norm. The idea is to start to pull back a bit as the INR increase rate goes up, trying to no overshoot (by too much). I've cases where PT testing was done in the AM and again in the PM. Often these folks are on heparin and waiting to get INR in range before discontinuing.

When I was hospitalized following a TIA episode, I was tested four times a day. I was on heparin, and they wouldn't release me until my INR hit 3.5. A neurologist was initially in charge of my case after I presented in the ER. My cardiologist released me three days later with a prescription for only Plavix and aspirin.

It was that episode that made me decide to go tissue.

 

[Guest]

Mary,
Testing 4 times a day and waiting for the INR to get to 3.5 shows that they
had, at best, miniscule knowledge of warfarin.

Warfarin depresses several clotting factors and they all are depressed at different rates. The INR does not present a true picture of what is going on until the person has been on warfarin for a week. It only provides a false sense of security. Did you ever play Chutes and Ladders with a child? Did you ever move their piece so that the child would win? That is about what they were doing with you. They just fooled you into thinking that it was safe to go home.

 

[Marge]

Wow, that sounds like a LOT of testing.
I've been on coumadin (for atrial flutter) now since about May of 2005. The first few weeks I tested once a week. Once I was in range (I am supposed to be between 2.0 and 3.0) they dropped me to once every two weeks, then once every three weeks, then once a month.
Now I seem to be testing once every five or six weeks. My INR will go up or down a point or two within the range (2.6. 2.7. 2.8). The anti-coagulation clinic doesn't seem to worry about such variations.
In August I had a fairly serious kidney infection, didn't eat for several days, was throwing up, etc. I went to ER. I was on IV antibotics & had more antibiotics after I got home. At that point INR went up to 3.3, and they did get concerned -- adjusted the dosage & sent me for testing once a week for a couple of weeks.
Once over the infection & off the antibiotics, I was back to normal range, so I am back to every five weeks or so. (I last tested Dec. 29 and will test next on Feb. 9). Except for the brief episode of infection in August my dosage has been the same: 5 mg. every day except Tuesday when it is 7.5 mg.
I am glad I do not have to test more often because sometimes they have a lot of trouble finding my veins! (Last week I went through four pokes and three technicians before the third one successfully got a sample.)

 

[jeffp]

could it possibly have something to do with the bottom line($$$$)

I don't think it is a bottom line issue as once he's in a facility, the testing is billed on a per test basis and a whole blood PT is reimbursed at around $6 per (Medicare rate). My guess is they are either following an old protocol, or just aren't to sure of what they're doing, so "more is better".

 

[catwoman]

Warren:

Seems I've seen Al Lodwick comment that the patients who are the easiest to manage are those who are extremely stable in everything, i.e., food intake, meds, etc. And it seems that a warfarin patient in a nursing home/convalescent center would fit that description.

So ... I still don't understand the need to test so often. Guess the nursing home folks just enjoy playing with yo-yos!