Low INR

[Raecee]

I have finally managed to find a good Cardiologist and a Coumadin Clinic in the area, but have recently found that my INR was low (1.4) rather than it is suppose to be (2.5 - 3.5).
I had been getting my bloodwork done at the local clinic, but they seem to be of the "No News is Good News" varity. So, by no one's fault but my own for not pushing the issue, I have been low for some time now..
Is there any consequences I will have to deal w/ because of the prolonged low INR ? My Cardiologist has done tests, but those came out fine. Other than partial blockage (plaque) in my legs. Just wondered.
Thank You,
Rachel

 

[Nancy]

I know you said you have found a "good" cardiologist and Coumadin Clinic, but I'm wondering why your INR has been low for some time. They should have been adjusting your dose to bring it up to the proper level.

Having a 1.4 INR when your target range is 2.5-3.5 is dangerous for you and you apparently will have to read someone the riot act to have them up your dose to get you to where you have to be. And do it today. Staying at that level is not a good thing for you. Clots can start forming and they can break off and travel in your body. They can also impair your heart valves.

1.4 INR is "stroke" level for my husband. He also can get TIAs at that level. His target range is the same as yours 2.5-3.5

I am very vocal when his INR is that low. It doesn't stay there long, I can assure you.

That means to me that someone doesn't know what they are doing.

Please get retested and have a good old fashioned "chat" with your Coumadin manager.

 

[Ross]

Rachel can you describe to me what all you do at your coumadin clinic.
What dose are you on over a week?
How often are you tested?
How long are you waiting to get those test results?
When a dose adjustment is given, how large or small is it?
What foods do you like and eat?

 

[catwoman]

Raecee:

Where in SE Texas are you? I'll be in Pasadena in 2 weeks (for a Saturday-only cat show).

 

[Raecee]

I'm living closer to Beaumont than Pasedena. I have been going to this Cardiologist/Coumadin Clinic for two weeks now. They are testing me once a week and are regulating my INR and doing thier best to get it up to par. As for the previous clinic.. it was not a Coumadin Clinic , just a health clinic. And unfortunately I did not realize the severity of a low INR (which has been quite low for some time now). Michelle has moved to to 7.5 mg of coumadin (off the warfarin brand and onto Coumadin itself) 5 days and week and 5mg the other two days.
As for my diet (need to get on one but afraid to until my INR us up how it should be) I eat normally.. salads, meats, veggies, fruits. and so on, but still enjoy the southern cuisine (will miss). I have taking the salt/sodium out of my daily diet as best I can.
I do appreciate the help.. I really had no foothold on this from the time I finally got out of the hospital. It's hard when you don't know enough to form the vital questions. And now I do, or am at least working on it.

Thank You,
Rachel

 

[Lisa in Katy]

Raecee:

Where in SE Texas are you? I'll be in Pasadena in 2 weeks (for a Saturday-only cat show).

Where in Pasadena? I live on the other side of Houston in Katy, but I love cat shows.

 

[Ross]

Don't deny yourself the foods you like. Eat them, but be consistent about it. Dose the diet, not diet the dose! This is one of the biggest mistakes made. Enjoy your food the way you always do, do not stop anything because of Coumadin. If your diet is stable, then the dosing can become stable, but if your denying yourself to get the INR right and then going back to the way it was, your going to seesaw all over the place.

Watch for hidden sources of vitamin k. Carnation instant breakfasts, Ensure, Boost, Nutritional bars, V8 juice etc. Those can drop your INR pretty good.

 

[catwoman]

Raecee:

Ditto what Ross says. I hear many people say they can't have salad anymore because they're on Coumadin. Hogwash! Eat your regular diet, just dose your Coumadin to fit what you eat, how active you are, your medicines, etc.

Katy:

The show will be 9:30 a.m. to 5:30 p.m. Feb. 12 in Campbell Hall at the Pasadena fairgrounds. Show flyer says Pasadena Convention Center, and I think that's a fancier facility near where we'll be. Don't know how much admission will be; it usually is about $4-$5 for adults.
I will be master-clerking the show -- compiling and consolidating records from all the judging rings -- and showing at least 2 cats, an Abyssinian female who became a grand champion last weekend and a Maine Coon female open (her first show as an adult).
If you are able to get to the show, I'd love to meet you! I will be near the judging rings, on an end of row.

 

[catwoman]

Lisa:

Oops! I called you Katy ... Sorry...
The address for the show hall is 7902 Fairmount (Fairmont on the flyer, but I think that's wrong), Pasadena 77507.

 

[Guest]

Is she Lisa in Katy or Katy in Lisa?

 

[Raecee]

Doing my best

Doing my best

Thanks Ross (and everyone else) for all the information . I realize that I need not give up many of my favorite foods, but I have found from the blood pressure tests and others that I still have partial blockage in my legs and need to loose some of my weight. The hard part will be the diet that my cardiologist wants me to go on or at least go by (South Beach) I find that it will be harder than quiting smoking (which I did during my time in the hospital 5 months ago ) NO, the food I speak of I am trying to alleave from my daily regiment is all the "fried" "southern" "fatty" foods that no-one really needs.
I was going through some of the other posts and forums and reading all the info that I have and have found that some of my teas that I like to drink (although not consistantly) may also be fouling up my INR tests. I am going to bring that up with Michele (she runs the Coumadin clinic) and see what she has to say about my teas. Also, I should and will ask about the Multi vitamin that I have been taking and make sure it's okay as well. Hopefully non of my other "good" habits will effect the coumadin or the Aceon ( 4mg daily) I am taking.
I do appreciate all the good works ya'll are doing here, and will post almost as much as I read.

Rachel

Don't deny yourself the foods you like. Eat them, but be consistent about it. Dose the diet, not diet the dose! This is one of the biggest mistakes made. Enjoy your food the way you always do, do not stop anything because of Coumadin. If your diet is stable, then the dosing can become stable, but if your denying yourself to get the INR right and then going back to the way it was, your going to seesaw all over the place.

Watch for hidden sources of vitamin k. Carnation instant breakfasts, Ensure, Boost, Nutritional bars, V8 juice etc. Those can drop your INR pretty good.

 

[Toronto Guy]

The Best Way to Dose UP

The Best Way to Dose UP

Dose the diet, not diet the dose!

At 15mg/day, my INR remains low - for the last 2 weeks stuck at 2.6

What adjustment would you suggest?

My Doc suggests an additional 2.5 mg on M,W,F

What's your opinion?

Is that the best way to dose it up?

Phil

 

[Guest]

A St. Jude aortic valve should be OK at 2.0 to 3.0, so it isn't clear why you want to increase the dose.

 

[Toronto Guy]

INR targets

INR targets

A St. Jude aortic valve should be OK at 2.0 to 3.0, so it isn't clear why you want to increase the dose.

Thanks for your reply Al

I was told 2.5 to 3.5

Wondering why the difference

Phil

 

[Toronto Guy]

A St. Jude aortic valve should be OK at 2.0 to 3.0, so it isn't clear why you want to increase the dose.

How relevant is this?
http://www.ctsnet.org/sections/innovation/valvetechnology/articles/article-1.html

Thanks in advance

Phil

 

[Guest]

In reality I keep my patients with STJ aortics at 2.5 to 3.5 also, but I was illustrating the point that if your INR was 2.6, then you were in range and there was no need to increase your dose.

The article you cited is a "state of the art" review. It covers a lot of studies, opinions and actual practice exampes. What it all serves to illustrate is that this is largely an art more than a science. My experience has been, if you don't get more than 0.2 units below the desired range and don't go above 5.0, then there is little risk of an adverse event.

Each person has to have their own variables figured into the equation. However, it seems that too many doctors try to make up many rules before they know the person's variables. They set ranges like 2.3 to 2.5 that are so narrow that all they do is frustrate people because they cannot maintain them. Or, they try to make adjustments that are irrelevant, as you stated when the INR is already in range. All this does is make your INR jump around and makes (probably) no improvement in your long-term outcome.

My philosophy is to make warfarin a factor in peoples' lives not THE factor. I try to make few dosage adjustments so that getting tested is a little nusiance, not an obsession. By the time people have been on warfarin for a year or so, they have probably had several dosage changes, many of which kept the INR in range for varying amounts of time. If the INR gets out of range, and I can adjust back to a dose that worked before then I am comfortable with that. I worry when I have to set a new personal high or low dose for somebody. Tweaks of 10 to 20% up or down are usually adequate.

A simple way to do this is to add up the total dose for 7 days. Divide the total by 7. This is then the amount up or down you want to change. Round this off to the nearest half tablet that you have and spread the change out fairly evenly over the next week.

If you take 40 mg per week.

40/7 = 5.7 mg

You have 5 mg tablets so 5.7 mg is roughly 1 tablet

So you want to add or subtract 1.5 tablets from the weekly dose.

If your old dose was

S M T W T F S
1 1.5 1 1 1 1.5 1

Then your new increased dose will be

S M T W T F S
1.5 1 1.5 1 1.5 1 1.5

Or the decreased dose will be

S M T W T F S
1 1 1 1 1 1 1

Then don't test too soon. Give it about a week to come to its maximum effect. If you already took this dose and it worked, I probably wouldn't even test for another month.

I had a doctor yeaterday who tested a guy after his first dose ever of warfarin and when his INR was not in range gave him a new prescription for 1 mg tablets and told him to add that to his daily dose. Totally irrational to expect the INR to be in range. And why make him pay for another prescription when adding two half tablets per week would accomplish the same thing (if it had been needed in the first place.)

I have also found that some Coumadin clinics run by pharmacists have had grumbling because only certain pharmacists could work in the clinic. So to keep the staff happy, they rotate everyone through the clinic. As a result none of the staff gets good at warfarin management. The result is that the staff is happy but the patients are not because they have seen their quality of care decline.