May I vent?

[mecretired]

My ins pays fully for lab testing once a month--but not convenient and I want to test weekly. So I purchased my own Coagucheck XS (thru ebay) and check my inr weekly myself and then go to the lab once a month or so. My cardiologist is cool with this--coumadin clinic not so much. If I have a reading that is out of range they will not take the info from me--it must come from Roche or a lab. So this is what just happened: inr readings as follows: 3/20 lab 2.0 (warfarin increased from 60mg/wk to 65mg/wk), 3/27 self test 2.7, 4/3 self test 2.5, 4/10 self test 2.4, 4/17 self test 2.2. So my instruction from the coumading clinic today was to go in for a lab test--I must do this before noon so they can send the blood by courier to Lenexa KS about 8 hrs away and the coumadin clinic can get results the following day (which will be Friday). I am currently taking 10mg on Sun, Tues, Wed, Thur, & Sat with 7.5mg on Fri and Mon. I am careful to test on Tues usually so I don't catch the 7.5mg day in my inr reading. I think I need to increase warfarin to 10 every day (70mg/wk). But she wouldn't tell me anything. I must lab test first. I told her since she won't accept my readings that maybe I should self dose and she said "We don't recommend that." She wasn't concerned at all that I was at 2.2 and that it had been coming down for 3 weeks. Anyway, I will lab test tomorrow, but I told her that if I didn't hear from her on Fri I would be taking 10mg instead of 7.5. What do you guys think about increasing to 70/wk?

 

[karla]

What is your target INR range?

 

[mecretired]

Sorry--2.5--3.5

 

[dick0236]

I assume your goal is 2-3. An increase from 65mg to 70mg (7+%) should increase your INR only a little. Your bigger problem may be self-dosing without clinic approval. INR clinics feel threatened by self-testing from both a "legal" and "job protection" standpoint. Problems like yours is why I elected to return to "office testing" after "self testing" for over one year. I only test monhly because my INR has remained very stale between 2.5-3.5 for the past several years. If I had to go back to weekly testing I would probably return to self-testing......even tho the problems with providers, insurers and equipment suppliers will "drive me up a wall".

 

[Freddie]

According to the on-line calculator: http://www.pace-med-apps.com/CoumCalc.htm
you are correct with the dosage of 10mg every day.


*When using the calculator start at "Continued Dosing" second line highlighted in blue. Fill in your "Target INR" range and "Currant INR". Directly underneath these two boxes, click either you "Day" dose or your "Week" dose then type in the dosage for the day or week. Then press the "Calc" button". Scroll down and your dosage for each day for the week (7 Days) will be there*

 

[RobThatsMe]

Hi,

Who said you had to test weekly?

You have to keep in mind that some of these Coumadin Clinics feel threatened by home testers.

I have been home testing for over 10 years.
Usually, I test on 2 week intervals.n Although during times on some medication, or post surgery, I test weekly.
At least once a year, I still want to have occational lab tests to validate that my home testing unit is within tolerence of the lab tests

Rob.

 

[yotphix]

Your experience is precisely the sort of thing that led me to conclude that I'm better off looking after things myself. As a result, I've had one out of range test (I test at random intervals ranging from 6-10 days so that I avoid patterns) in two years. I dose myself without any trouble, and for even my dose has been stable for 18 months, and was stable for a year before that. Do what you think is best. Seems like you have a pretty good handle on how it all works.

 

[catwoman]

Mecretired:

After being on warfarin nearly 9 years, I still do not understand why some medical professionals insist that LAB draws are the Bible of INR tests and insist that patients who home-test come in for a periodic draw.
Many highly respected anticoagulation clinics use POC (point of care) monitors -- CoaguChek or INRatio machines. According to Dr. Jack Ansell (google him if you don't know who he is) has been a big proponent of POC care, rather than lab draws, because you have the patient face to face and can quickly determine a dosage change and chat with the patient about it.
The charts medical professionals use are pretty the same that many of us here use.
I chatted with my family doctor's nurse yesterday about taking cipro for a resistent urinary tract infection. When she mentioned cipro, I knew it would increase my INR. The nurse was aware that I home-test and adjust my own dosage, so she just mentioned that I might want to reduce my dosage.
My family doctor writes my warfarin RXes and signed paperwork for both monitors I have owned. When I have my annual physical, he just asks what dosages I use and if I've had any problems.
Both he and my cardio say that I can do as good of a job if not better than the employees who run INR tests (on CoaguCheks) at their practices.

Sorry you have to suffer through this Coumadin clinic's rigamarole.

 

[AgilityDog]

Me too. My cardio lets me self test and self dose. I usually bring him a copy of my INR chart when I see him, and he refills whatever dosages I request. His anti-coag certified nurse is always available by phone to assist.
I don't know why you even bother going to the lab, if your doctor will write you the scrips and you self test. You CAN do this.

 

[newmitral]

Hello mecretired,

If your cardiologist will take on the responsibility of prescribing the coumadin and helping you dose for proper INR, or if you can get your regular primary care doctor to do it, then go for the home testing only and say goodbye to the coumadin clinic. If you get your doctor/cardiologist to prescribe the home testing, then almost all insurance companies will pay for that just as they are paying for the lab testing now. The catch is that it must be by doctor's prescription, not just you getting the machine yourself on ebay.

My primary care doctor was willing to take on my warfarin dosing/prescribing and wrote the prescription for the home testing kit. His office even coordinated everything with the Phillips/Alere folks and the machine just showed up at my house one day.

The one thing that my doctor feels is important, which seems to differ from the care you are getting at your coumadin clinic, is that he likes to have me take the same exact warfarin dose every day, even if I split 1mg tablets in half. Thus, rather than your current dose of 10mg one day and 7.5mg the next, he would likely recommend 9mg each day (63mg/week versus 65mg/week = close enough). This removes the concern you expressed of testing after the low dose day, since all days are of equal dose. It just means taking 2 smaller dose pills/day that add up to the desired dose rather than being restricted to the single-pill higher dose values of only 7.5mg or 10mg.

Most coumadin managers won't be too concerned if you test at 2.2 one time after being in range (2.5-3.5) the past 3 weeks. The 2.4 reading is marginal, so that's a toss-up.

In addition to the online coumadin dose calculator, I recommend you check out the article at:
http://www.hopkinsmedicine.org/hema...ing_algorithm_Kim_YK_and_Kaatz_S_JTH_2010.pdf

Table 1 in that article has a nice, simple dosing algorithm you can use as a guide, or a validation of the advice given by your ACT manager.
The simple algorithm table makes it easy to check the advice you may be getting from your clinic.

Going from 9mg/day to 10mg/day as you suggest would certainly be within the guidelines of most dosing protocols from your test history, but make sure you get your doctor's OK. Your doctor might want to try 9.5mg/day first, rather than going right to 10mg/day, particularly since you say your dose was just increased on 3/20. You did not indicate whether there was something else you are doing or medication you may be taking that might be causing your INR to drop in the past month necessitating two upward dose adjustments. Also, how stable was your dose/INR in the prior few months? Your doctor will need to take all this into account as part of your coumadin management.

As you already know, the home testing is much more convenient, so get your doctor to make it official and cut out the coumadin clinic if they are not doing things to your satisfaction.

 

[Protimenow]

It's good to see that you now have a more modern, easier to use meter.

When I had an ample supply of strips for my InRatio, I tested weekly - unless my INR was too low and I needed to monitor a dosing increase. Now, I'm testing every 2-3 weeks (though I don't like waiting that long), and looking for some recently expired strips that I can get inexpensively.

I don't recall the reason that you're taking warfarin - but I don't think that a 2.2 is particularly scary.

I agree that taking the same dose daily can help keep the INR steady from day to day, but the slight adjustment a couple times a week shouldn't be too big a deal.

I self test, and self monitor, and I show my doctor my INR DIARY to prove to him that I'm on top of things.

You should be able to self test (and probably to manage your dosing), too.

It'll be great to see what your INR is in the future.

 

[mecretired]

INR came back today (from yesterday morning's lab) at 2.2--the same as from my Coaguchek xs on Tues. My coumadin clinic actually agreed with me that I should increase to 70mg/wk. and retest in 2 weeks. I just do not feel comfortable checking less often than weekly--maybe 5-10 yrs down the road if I stay stable. In April of last year I was on 57.5mg/wk--now 70! I would also feel better taking the same dosage each day, but my coumadin clinic doesn't even want me to have more that 1 dosage of pills--they went off on me about that! I do have 5mg and 2.5mg so I can do some splitting when I need to. So I will continue to test weekly at home and if I come up out of range I know I need to go to the lab as my coumadin clinic doesn't want to talk to me unless I've been to the lab. I will probably be doing some self dosing, too. Thanks for all your help and moral support.

 

[Bina]

INR came back today (from yesterday morning's lab) at 2.2--the same as from my Coaguchek xs on Tues. My coumadin clinic actually agreed with me that I should increase to 70mg/wk. and retest in 2 weeks. I just do not feel comfortable checking less often than weekly--maybe 5-10 yrs down the road if I stay stable. In April of last year I was on 57.5mg/wk--now 70! I would also feel better taking the same dosage each day, but my coumadin clinic doesn't even want me to have more that 1 dosage of pills--they went off on me about that! I do have 5mg and 2.5mg so I can do some splitting when I need to. So I will continue to test weekly at home and if I come up out of range I know I need to go to the lab as my coumadin clinic doesn't want to talk to me unless I've been to the lab. I will probably be doing some self dosing, too. Thanks for all your help and moral support.

Sounds good for now. Take the 70 mg per week and test yourself next week if you are concerned about any change.
I like to keep my INR at around 3.1 so that I have lots of wiggle room for spinach and broccoli !!