Levels dropped again

[Orangebrittainy]

I am beginning to wonder if I am on too low of a dosage or something. My INR was in the 1. something again. I forgot the exact, but I am again waiting for the phone call to tell me what dosage to take for today. I will get the exact and write it on the calender. I went in to check early this morning and was not fully awake or able to think clearly so I forgot to write it down.

I haven't missed a dose since the last check over a week ago. I am starting a food log to see if I can track something down. Any other suggestions??

 

[Herb M]

Someone not taking coumadin/warfaran will have an INR of ABOUT 1.0

YOU NEED TO LOOK AT THE PILLS TO MAKE SURE IT IS COUMADIN/WARFARIN

 

[dick0236]

From your profile, it seems you had your surgery recently? Normally, with an INR <2, the protocol would be to increase dose by 15-20% and recheck in a week. Probably, your activity level is increasing and that would indicate a higher required dose. I would not worry about a "food log". My advice would be to continue making smaller corrections 'till you stabilize in your "range".

 

[Orangebrittainy]

I've checked them to the images post in one of the posts. When ever they increase my dosage my INR will go up but when I go back to one pill a day it drops back down. I am currently on 2.5 mg pills

 

[Protimenow]

In an earlier post, you indicated that you were five (now six) weeks post-op.

It also said that you were only taking 2.5 mg/day and that your doctor said to increase dosage to 10 mg and then drop back. It also said that you were eating a very poor, marginally nutritious diet.

It doesn't sound like 2.5 mg is nearly enough. Making that big a spike (4X) and then letting it drop back to 2.5 doesn't sound like good management (to me, at least). Plus, while you're recovering from surgery and becoming more active, your INR will change.

Also - if you're still on the (non)diet that you mentioned last week (very little nutrition), your INR might also be prone to variability when you change it back to a healthier one.

I would explain to my doctor or whoever is managing your anticoagulation that your INR is still below 2, and that you are concerned that you may need to adjust your dosage. If you've made changes in your diet, you should also point this out.

Staying below 2 -- especially closer to 1 -- is not good, especially while your heart is integrating that new valve. If you don't get a good answer from your anticoagulation manager, you may want to look for answers from someone with more experience managing anticoagulation.

 

[kfay]

Brittainy, You are moving around much more now than you were when you were in the hospital. Walking your 2 miles a day is a good example. Your INR is probably changing because of this. That is normal after surgery. Someone needs to stay on top of this better though. If you are on the low end of 1, you are basically the same as someone who is not taking coumadin. I'm sure you know that's not good for someone with a mechanical valve. Does your cardio know what is going on?

 

[AgilityDog]

Why are you dropping back down to one 2.5mg/day? It doesn't make sense that you would be told to increase your dosage only for a short period of time. When I increase or decrease my dosage, it is permanent until my INR indicates a change is necessary. Dosages are based on a weekly total, broken down into daily increments.

An increase of 2.5 mg/day to 10 mg is a HUGE jump, certain to swing you much higher. It sounds like you need a higher dosage, for sure. If you need 10 mg (or 70 mg/week) to get and keep your INR in range, then a dose of 2.5 mg/day, or 17.5 per week, is not going to do anything for you if you return to that dosage.

Either you are being mismanaged, or perhaps you are misunderstanding your instructions. You should not be getting daily dosage changes!

That said, after my most recent surgery, I started at a dose of 21/week or 3mg/day. I quickly got moved back to my presurgical average of 25/week, but that still wasn't enough. I am currently taking 34 mg/week, being 5 mg daily except 4 mg on Wednesday. I'll stay at this dosage until my INR says I need to increase or decrease dosage based on weekly tests.

I hope, with your INR at 1.x, that you are still bridging with Lovenox or generic if you have a mechanical valve. I had to bridge for a total of 5 weeks!

I respectfully suggest you use the coumadin dosing calculator, input your current INR and current dosage, and see what it says. I expect you'll need an increase of as much as 15-20% in dosage over the next week, if your current INR is 1.x. Recheck in no more than 3-4 days, to a week. You may have to increase dosages several times as you heal and your diet improves before you get to a stable dosage.

 

[ShezaGirlie]

YOU NEED TO LOOK AT THE PILLS TO MAKE SURE IT IS COUMADIN/WARFARIN

ABSOLUTELY...and I'm shouting since right after surgery I took another pill *thinking* it was warfarin..:eek2: I still remember being on the phone with my cardio who was probably pulling his hair out with frustration when he asked me to look at the pill and make sure it was warfarin. It wasn't..:eek2: I had been taking the other pill for about 5 days, so check it out now..!

 

[Bina]

Janie, did you switch your warfarin with Ativan ?
(and maybe were on the edge of a stroke but really didn't give a darn......)

 

[ShezaGirlie]

Janie, did you switch your warfarin with Ativan ?
(and maybe were on the edge of a stroke but really didn't give a darn......)

What's Ativan? That's a sleeping pill, I think.. No, it was a lisinopril pill which was also white.....like my 10mg warfarin. So instead of taking 10mg lisinopril, I was taking 20. Wonder what that did?:biggrin2:

 

[Bina]

Britt, you have gotten good advice here. Increase your daily dose and continue that for a few days until your INR increases. A slow climb is much safer and easier to control along with taking a Lovenox shot until you are back in range. A single large dose on one day will bounce you around.

 

[Bina]

What's Ativan? That's a sleeping pill, I think.. No, it was a lisinopril pill which was also white.....like my 10mg warfarin. So instead of taking 10mg lisinopril, I was taking 20. Wonder what that did?:biggrin2:

Low dose Ativan is small and white.....a mild happy pill that is good to take before going to the dentist.

 

[ALCapshaw2]

Who is managing your Coumadin / Warfarin Testing and Dosing?
It sounds like they are CLUELESS based on jumping from 2.5 to 10 and back to 2.5

How long has your INR been below 2.0?
If more than a few days, it would be wise for you to be taking Lovenox Injections to protect you from Clot Formation and Possible Stroke until your INR is back in Theraputic Range. Your Coumadin Manager can prescribe this. Hopefully they know how to dose Lovenox better than they seem to understand Coumadin Dosing.

'AL Capshaw'

 

[Lynlw]

I've checked them to the images post in one of the posts. When ever they increase my dosage my INR will go up but when I go back to one pill a day it drops back down. I am currently on 2.5 mg pills

What was your dosage before the day you forgot to take your pill? When they told you to take 10 for the 2 days was that to make up for the missed dose in addition to increasing it because you were so low? Its a little confusing when you say 1 or 4 pills, maybe it would be helpful to say the amount you take.

 

[Protimenow]

You also mentioned something about running real low on your 2.5s and not being able to get a refill without borrowing from one of your kids. Were you able to see if the MD had some coumadin samples? Were you able to check into generic 5 mg warfarin that you could break in half if you only need 2.5 (which doesn't sound like enough, based on your recent experience)? (The generics at some pharmacies - Target, Walmart, Kroger/Ralphs are $4 for 30 and $10 for 90 except in California where the 5 mg are somewhat higher).

Do you now have an ample supply of Warfarin?

 

[Orangebrittainy]

I started recording the INR and dosage information on 11th. In the two weeks before that my INR either in range or really close to range.

on the Monday 11th at Duke follow up. INR of 2.3, Surgeon wasn't worried and I stayed on 2.5mg a day.

On the 20th (wed-10 days later) with my PCP, INR 1.2 I had reported it a little higher on here, but I asked the nurse again what it was. I had read the 2 backwards. I missed a dose on the 19th. Was instructed to go to 10 mg for the 20th and the 21st.

I went in on the 22nd to retest. Got an INR of 2.1 and was told to take 5 mg on the 22nd and 2.5 mg starting on the 23rd until my next appt on the 27th

Yesterday on the 27th I tested 1.8, so its not quite as bad as before but still low. It seems like this round she is trying for a more steady increase instead of the radical changed last time. I take 5 mg MWF, and 2.5 TTSS. Does this sound a little better? They want me to retest in two weeks though. I am not sure if I should check in a week to see if it helped, or if two weeks would be easier to see, I will be asking my cardiologist

I told the PCP about my lack of nutrition and also let them know that would be changing this week that I would be seeing an increase in veggies and what not. I also shared my walking and what not.

I also am going to bring my calender to the cardiologist to show him and ask him about management.


To answer other questions. My PCP told me she prefers to write her warfarin patients for 100 tablets and write directions to take as directed so they can get refills without a fuss. She said to call when I was low and I would be able to pick up the prescription most likely that day.

 

[catwoman]

My PCP told me she prefers to write her warfarin patients for 100 tablets and write directions to take as directed so they can get refills without a fuss. She said to call when I was low and I would be able to pick up the prescription most likely that day.

Smart PCP. That's what my doctor does....

 

[Bina]

Britt, since you are still a bit out of range and making dosing changes it is wise to test every week.....going for 2 weeks is too long to catch things that are possibly dangerous at this point. It does sound like things are going better for you though.

 

[Protimenow]

Yes, it sounds like your PCP is listening to you. At 2.5/day you're taking 17.5 mg/week (which seems like a pretty small dosage). Increasing it to the current dosage you indicated raises it to 22.5 - it's more than 20% higher, so if you weren't already running so low, even this increase could be questionable. It seems like a good start, but I agree with others that you probably shouldn't have to wait two weeks to see how the new dosing works (except that you DO want to see the results of those 5 mg doses after they've had a chance to work).

Your PCP prescribing warfarin 100 at a time is a good idea - I don't know if your insurance pays for 100 pills at a time -- if not, there are pharmacies that will sell 90 generic Warfarin for $10. This approach is an alternative that you may want to consider - it may even be better than your insurance co-pay (assuming, of course, that you're fortunate enough to have insurance).

2.5 is an interesting dosage because you can create many different dosages (all multiples of 1.25) from them. If you need 7.5, it's three pills - 3.75 is 1 1/2 pills, etc. When you and your doctor get a handle on your dosing, it may make more sense at that time to add pills of different dosages to your dosing arsenal - perhaps a 2 (that can be broken into 1s if needed), perhaps a 5 (just to save money if you NEED a 5 and don't want to waste an extra 2.5 mg pill to make 5).

Your diet and increasing activity probably WILL produce changes in your INR -- you may want to monitor these more frequently than every other week -- especially because your INR is already pretty low and if you start eating greens that contain high levels of Vitamin K, the combination may push your INRs dangerously low.

When you (or your insurance) can afford it, getting your own meter, so you don't have to wait for others to say they want you to come in, can reduce a lot of the insecurity about your ACTUAL INR. Being able to test at home (or wherever) is an empowering feeling. (I can't and won't recommend it, but I bought my meter on eBay and am confident in its accuracy - even after comparing a result to a hospital lab. There are quite a few meters out there, and not all are extremely expensive. But, of course, this is up to you).

 

[Orangebrittainy]

Saw my cardiologist yesterday. I showed him the same data I showed you and He and his office are going to take over monitoring my INR completely. He said if my surgeon found out how my PCP spiked the dosages the way she did, my surgeon would probably manage to bite her head off from two hours away. He said with my INR dropping to 1.2 and 1.8 (both after several days of 2.5 mg doses) He wants me to try 5 mg doses every day and will retest me on Monday.

He also is said that after I am therapeutic for a while he will have his office manager arrange for me to get training to Monitor at home. He has a couple of patients that do this already and they are doing well, he thinks I am a perfect candidate for it.