INR Unstable

[Kristen]

Hello,
I need some more advice. I had my AVR on 5/30/12 at Brigham and Women's Hospital in Boston, MA and was told that I would need to be in the 2.0 to 3.0 range for coumadin. I cannot maintain that range, I've actually only been up to 2.0 twice, once in the hospital post op for Afib they put me on a heparin drip and once two weeks ago. I get tested every week, I take my coumadin at the same time everyday, I haven't changed my eating habits, but I have increased my exercise. I currently am taking 10 mg six days a week and 12 mg one day per week and my latest INR's were 1.6 this past Monday, 1.8 last week, 2.0 the week prior and 1.8 the other weeks or less.

I called my Cardiologists office today to ask if I should be concerned about these levels and the nurse I spoke with made me feel like an idiot for calling. She said I should trust Brigham and Women's Anticoagulation clinic because that is what they do and they are increasing the dosages so it shouldn't be a problem. My cardiologist is on vacation until October 9th. My sister is a nurse and she said I should be concerned and that's why I called the cardiologist's office, so now I don't know what to believe. When I have my levels tested at the lab they just report them to the anticoagulation clinic and then it stops there, my PCP and Cardiologist aren't notified of the results. Should they be?

After surgery it was drilled into me that I needed to be between 2.0 and 3.0 and when I was in the hospital for the Afib the admitting cardiologist wouldn't let me leave because my level was too low at 1.6, so any comments, suggestions?? Thank you in advance for all your help, it's so nice to have this board!!

 

[kfay]

Hello,
I need some more advice. I had my AVR on 5/30/12 at Brigham and Women's Hospital in Boston, MA and was told that I would need to be in the 2.0 to 3.0 range for coumadin. I cannot maintain that range, I've actually only been up to 2.0 twice, once in the hospital post op for Afib they put me on a heparin drip and once two weeks ago. I get tested every week, I take my coumadin at the same time everyday, I haven't changed my eating habits, but I have increased my exercise. I currently am taking 10 mg six days a week and 12 mg one day per week and my latest INR's were 1.6 this past Monday, 1.8 last week, 2.0 the week prior and 1.8 the other weeks or less.

I called my Cardiologists office today to ask if I should be concerned about these levels and the nurse I spoke with made me feel like an idiot for calling. She said I should trust Brigham and Women's Anticoagulation clinic because that is what they do and they are increasing the dosages so it shouldn't be a problem. My cardiologist is on vacation until October 9th. My sister is a nurse and she said I should be concerned and that's why I called the cardiologist's office, so now I don't know what to believe. When I have my levels tested at the lab they just report them to the anticoagulation clinic and then it stops there, my PCP and Cardiologist aren't notified of the results. Should they be?

After surgery it was drilled into me that I needed to be between 2.0 and 3.0 and when I was in the hospital for the Afib the admitting cardiologist wouldn't let me leave because my level was too low at 1.6, so any comments, suggestions?? Thank you in advance for all your help, it's so nice to have this board!!

I am not a coumadin management pro, have only been on it 3 times for short courses. I'm assuming you have a mechanical valve? If so, I think you have every right to be VERY concerned about your INR not being 2.0 or above. Were you at 2.0 before they discharged you from hospital after your surgery? It has been long enough since your surgery that they should have been able to get you up to your range, at least more than 2 short weeks. If I were in your shoes, at 1.6, for that long, I would want louvenox shots and demand that they increase my dose to get me in range. I would also reach out to your pcp and let him know what is going on, since your cardio's nurse is playing gatekeeper and most likely won't let you get to him. I'm sure others who have much more experience with coumadin will come along to give you some great advise.

 

[lance]

You have every right to be concerned. Warfarin is metabolized in the liver and anything that increases the volume of blood through there will lower your INR. An increase in exercise would do it. That nurse had no right to treat you that way. Don't let her do it again. Your warfarin needs to be increased and now.
I have been managing my husband's INR for several years and although he has never been out of his range (2-3) I would increase his weekly dose by 10% and test in 4 days should he ever get that low.

 

[Protimenow]

I'm curious WHERE you are getting your INR tested (if the clinic at Brigham & Woman's Hospital is doing the testing, they should know better than to let you continue with an INR that is so low).

For a short period (a week, perhaps), it's probably okay to be between 1.0 and 2.0, but I'm one of a few here who probably let it run that low for more than a week. In my case, my meter was telling me I was between 2 and 2.6 - but the actual lab value was 1.7 (and probably less). I had a minor stroke (a TIA), and certainly don't want it to happen again - or to anyone else.

It wouldn't hurt to get your own meter - this way you can keep an eye on your INR and seek help if your INR is out of range.

If you have good insurance, and your INR is below 2, you might consider going to an Emergency Room (because you ARE at risk of a TIA), or to another doctor right away. I used to be less careful about being below 2.0 for a short time -- and studies still say that it's safe for about a week, but that you should increase you dose when you first detect that you're below range -- but at this point, it seems only prudent to get another test - confirm the actual value (if labs can be trusted to be much more accurate than meters), and to make sure that your INR IS in range.

Getting medical care now - even at an emergency room - will cost you or your insurance a lot less now than treating you for a stroke in the future.

Again -- if you can, get yourself a meter. Learn how its values correlate to the lab values, so that you can make a reasonable guess of your closeness to being in range.

Don't mess with it. You're scaring me.

 

[Guyswell]

1.6 seems pretty low. You're right to ask questions. When my INR became too low awhile back, my cardiologist prescribed Lovenox shots for a few days until my INR was within range. I'm sorry I don't remember the actual INR value but it may have been 1.4 or 1.6. I have my blood drawn at a nearby independent lab and the results are reported to my cardiologists office and their internal pro-time nurses the next day. There's never a problem with my cardiologist and his nurses knowing exactly who is responsible for managing my INR. Consider calling your heart surgeon's office and discussing it with them too.

 

[Guyswell]

I should add that for the past few weeks my INR has been hovering around 1.9. The cardiologist's office has been gradually increasing my dose but has not mentioned Lovenox shots again. When the nurse was quizzing me about possible causes for the persistent low INR, I mentioned that I had a few beers over the weekend. The nurse said that would not have caused my INR to be low and it was probably helpful that I had done so. If you're not inclined to visit the ER tonight, consider a glass of wine or a beer.

 

[Freddie]

According to the dosing calculator you should be increasing your dose 5% to 10% and re-test in one week.
With an INR below 2.0; 11mg per day is suggested.

It's been said 'that we take the dosage that is needed', so don't let that bother you. But you need to talk to your cardiologist to let him/her whats going on.

 

[JimL]

I would never trust an anticoagulation clinic until after they had won and earned my trust. You are the best person to manage your own INR. Regardless of what anyone else tells you, increase your weekly dosage of coumadin. I would suggest that you are a person who needs a higher than normal level of coumadin to stay within range, and perhaps that means you could increase more than normal. You are currently taking 72 mg per week; Freddie suggests 11 mg per day, or 77 per week, which sounds good. At that level, the exact dosage isn't so important; in other words, use the coumadin pills you have. Take 12 mg three or four times a week, and 10 mg the other days, if that works out. I recently got my own INR meter, which has worked out very well. I contacted www.roche.com and they made everything work for me. Do what you need to do, and then relax, you'll be fine.

 

[Scott]

Hi kristen. I agree with the others. If my inr dips I usually make a one time 1/2 dose adjustment to get me back in range. I have also been running more so I have been taking that extra 1/2 dose once a week, every week for about a month now. For me, I like to be in control of my inr. I have been below 1.8 and above 4.6. before home testing. Now I stay between 2.0 and 2.5. I will say that you are still healing and my inr didn't stabalize for almost 10-11 months. If you are taking iron or eating things that contain vit k that will change things. I was eating cashews by the handfull for a snack all the time. I found out they have lots of vit k.

 

[DanielB]

Hi Kristen. I am coming up on one year post AVR and my INR is still moving around a bit as I get more and more active. Recently after a really busy & stressful week (by far the worst since my surgery) my INR dropped a full point! Lesson learned. I'll watch my INR really closely when I am doing tiring things in the future. That's part of what for me is the learning curve in all this INR stuff. My cardiologist told me not soon after my surgery that 'in six months you'll know more about your INR and what effects it than anyone' -- he was right. I have noticed that the coumadin managers my health group uses to set my dosing and schedule lab tests clearly had a chart that skewed my range too low - hovering around 2, leaving me exposed to drops below that if something impacted it and, as you may have noticed, far more things will bring your range down than increase it. I have come to learn that the best thing for me is to be my own advocate and to question anyone telling me something on my coumadin dosing or time between tests that I am uncomfortable with. The inlcudes my coumadin clinic, who has always backed down and allowed me to go with dosing I think is more appropriate all the way up to the head cardilogist at the hosopital recently when I was in for a pacemaker implant. My cardiologist listened when I expressed my concern about the 'low end of the range' management and directed my coumadin nurses to manage to a 2.5-3.0 range instead the broader 2.0 - 3.0 range. I recently did a rare 'mis a dose' and, instead of dropping into the sub-2.0 range, I came in at 2.3. Much better. I also have a home testing machine that allows me to test in between the times they want me to come in, which they try to stretch out whenever possible. I have found it gives me a great piece of mind having that available to me.

Bottom line for me is, make sure you are comfortable what what your coumadin management is and don't be afraid to ask the questions to get to that point. That nurse was out of line when she made you feel like you were questioning thier authority. I'd make sure your cardiologist hears about that and find out how you can get better information and from whom in the future. Once you get ypour INR reguolated, and I'm sure you will, I expect it will become routine as it has for so many others as demonstrated on this site.

Best of luck,

Dan

 

[lance]

Google for ACForum.org..AC=anticoagulation.
This site is managed and populated by medical professionals and has a link to "expert management" locations or words to that effect.
None members have access to publications and contain a wealth of information.
Healthy bones require Vt. K.

 

[drivetopless]

Definitely look into getting your own meter. It will help you learn about how your body reacts to coumadin with lifestyle changes.
Since it seems you've never maintained an optimal range there is some concern.
I will say it took quite a while to get stable after my surgery, but as time goes by it gets more consistent (but there are occassional spikes or dips which can be attributed to change in diet or activity).

Do yo have a mechanical valve? If so, what type?
I have an On-X valve so my recommended range was about .5 lower than typical. However, when I had a bout of afib that range was raised temporarily. Now that the afib is resolved, by target INR is 2-3.

However, my surgeon told me with the On-X that a range of 1.5 - 2.5 was okay with an aspirin with the coumadin. I found that it was harder to maintain the lower end of the INR range, so my cardioligist and I settled on the 2-3 range. It has been key in maintaining my INR without having to tweak the dosages very often.

I find it is more consistent if I :
1. take a daily vitamin with a small amount of Vit K
2. Eat one salad every day (or eat the same amounts of greens every day).
3. Exercise consistently.


Social drinking seems to make INR higher, so I try to minimize that, but I do have an occassional glass of wine with dinner. The key is to be consistent.

Good luck. You are right to question the medical advise you are getting. If you have a complication, you are the one who will suffer so take ownership and be involved. If someone gives you grief, find someone who will work with you and who appreciates you being involved.

 

[DougLR]

I'm sorry about your difficulty in regulating your INR. I've been on Warfarin for over twenty years due to Afib. I've never had problems controlling it until June of this year (six months after my valve repair surgery). I have a CoaguChek meter that I use weekly. I try to be consistent with my diet, including a salad every day. My doctor took me off several blood pressure and Prilosec meds. after I was doing well in cardiac rehab. classes. I used Tylenol and TUMS per the recommended dosages. About two weeks later my INR went from 3.2 to 4.2 in one week, then to 5.9 when I got to the E/R a day later. Six units of blood were required. No one knew what caused the sudden increase. Scary!

 

[Guyswell]

Doug,

Why did you need six units of blood?