Low INR for 2 weeks

[patient'smama]

Hi, My sixteen year old daughter had an aortic valve replacement with a St. Jude's mechanical valve on July 24, 2008. Everything went well, and we were out of the hospital on July 30th.

Fast forward to today, after a couple of ups (to 3.9) and downs (to 2.1) her INR is still hovering below her range, (which is 2.5-3.5). Last week it was 2.4, this week despite an increase in the Coumadin, her INR is 2.2. The anticoagulation nurse seemed unconcerned - she's trying to increase the dosage slowly so as to avoid drastic upticks, but I'm a worry wart. Isn't two weeks below level unacceptable? How dangerous is this? I know the symptoms of a blood clot, but isn't it safer to be a bit high on the INR than a bit low, especially for this long?

This might be partly my native anxiety, I just went back to work and now my husband, her dad (who is incredibly responsible and WAY more relaxed than I am) is taking over the anticoagulation appointments. He's not really worried about it either. Also, I know it's so soon after surgery and INRs are not expected to be stable or anything.

I know I can't solicit medical advice here but if anyone has thoughts, anecdotes, or sites I can look at I'd be grateful. I'd really rather also not worry about this. I'm probably going to call the nurse today, but words of wisdom from experienced patients are worth a lot!! Thanks and I'm so glad for this board - I lurked for 6 months prior to my daughter's surgery and found so much comfort and reassurance!!

 

[Ross]

With an aortic valve, as long as she's above 2.0 I wouldn't worry. Below that and I'd be wanting some Lovenox iinjections until she's above 2.0.

Can you post her entire weekly dose, any other meds she's taking including herbal supplements or over the counter, what type of diet she's eating and we'll better be able to tell what's going on.

It's always fun when they aren't far out from surgery. Simply being more active will decrease her INR, but for all the bouncing around, I'm thinking there's more to it then simply more activity.

If you want the best Coumadin sites with no nonsense info look at these two, besides us of course.
www.warfarinfo.com
http://www.aafp.org/afp/990201ap/635.html

 

[Karlynn]

Welcome!

If you haven't read the "Sticky" posts at the top of this Anticoagulation forum, I recommend you read them. You may find some things in them that will help set your mind at ease since you and your daughter are new to this.

 

[Guest]

Her warfarin manager is correct to not be very concerned. I agree with what the others wrote and add that as she recovers after surgery she will need more warfarin. She is eating more normally, getting more exercise etc all of which contribute to the need for more warfarin.

She also needs to know that she must never get pregnant without having a plan in place with a highh-risk OB doctor. There is a high risk of facial deformities if she is on warfarin during weeks 6 to 12. There are ways of working around this. It does not mean that she cannot have children.

Most teens will rebel against the warfarin at some time. In the future, a low INR may be a sign of intentionally skipping doses.

These are not thin g to put high on your worry list but things you need to know. You know best when to discuss them with her.

 

[Bina]

Hello and welcome!
An INR of 2.2 should be fine for this week, and with an increase of at least 5% of her weekly dose, she should get back in range again.
Hopefully you have a daily pill box so no pills get forgotten....relax, all is good.

 

[ALCapshaw2]

Congratulations! Your Motherly Instincts are RIGHT ON.

If only more anticoagulation managers understood that it is usually safer to be a bit on the high side than below 2.0

The 'usual' recommendation for a Mechanical Valve in the aortic position is 2.0 to 3.0 so her Doctor is giving her a little extra margin by raising it to 2.5 to 3.5 (which is the usual recommendation for the Mitral position or patients with other possible stroke risk factors).

My thinking is that anything between 2.5 and 4.0 is nothing to worry about and 2.0 to 5.0 is nothing to get overly excited about, just make *small* changes in dose to 'ease back into range' (as her nurse wisely recommended).

The last post is from our resident Certified AntiCoagulation Care Provider, AL Lodwick, who retired from managing his own Coumadin Clinic not too long ago. His website, www.warfarinfo.com is a TreasureTrove of current and accurate information on living with/on anticoagulation.

Look for the window highlighting his one page "Dosing Guide". It's the best $5 investment you and your family can make in learning how to make appropriate Dose Changes for different INR readings and recommended ranges.

With that guide, you can 'double check' the recommendations from her anticoagulation manager. My clinic uses the latest guidelines from C.H.E.S.T. and our discussions for out of range adjustments usually go something like this: "Well should we try a 1mg/week or 2mg/week dose change". Small changes have always worked well for me for several years now. Al's guide gave me confidence that my managers 'knew their stuff'. (unfortunately not all anticoagulation managers / nurses are as well trained).

Well, here another recommendation (to second Bina's):
Use a 7 day pill box.

I also have a 31 day spreadsheet listing ALL of my medications which I check off as I take them (some morning, some evening).

When I miss a dose of Coumadin / Warfarin, I go ahead and take it.
Then split the next dose in half and spread it out over 2 days.
This way, I minimize my 'missed time' but never end up taking a Double Dose either. By Day 3 I am back on schedule with the same overall weekly dose. Works for me.

'AL Capshaw'

 

[briansmom]

I think that you have gotten good advice here.
I just wanted to say welcome to the site. My son is now 18. He was first put on coumadin when he was 16. Unfortunately, he has permanent heart damage and does not want to accept that he needs to live a different life from his friends. It has been quite challenging for us to work through these past two years. He did have a time where he was skipping doses, so I agree you should be watching for that.
Please feel free to ask any questions.