Missed Warfarin doses

[Barry]

Read warrenr's horror story in "Heart Talk" about his dad stroking out after 4 days off Warfarin. Led me to wonder about something...

I'm taking that story to mean that 4 days without Warfarin clearly is potentially fatal. But what about 3, 2, or 1? How paranoid should I be if I go a day without a dose? [Have mechanical mitral valve]

BTW, what I do if I realize in the morning that I forgot to take my meds before I went to sleep (thankfully, not very often) is that I take my Warfarin then in the morning, and the usual dose at bedtime the evening of that day. Now, that's not the instructions the pharmacist gave me - I was told that if that happens with Warfarin or any other drug to just skip the missed dose. I follow the pharmacist's advice with every drug but Warfarin.

Hasn't yet happened, hopefully won't, but I presume that if it's not until the next evening that I realize that I'd missed a dose the previous day, I shouldn't double the dose to compensate that evening.

(I'm rather paranoid about missed doses, always carry at least a 3 day supply of meds in a water-tight container on my key-ring.)

 

[Johnny Stephens]

I've read several stories on here from people who "bottom out" when directed to skip a dose for whatever reason, so it's obvious that every missed dose increases your risk. Whether or not that directly translates into a stroke for a particular individual, gets into a statistical exercise. Arrrrgh.

My approach is that missing my dose is "bad", and I make every effort to comply. I've only missed it one time, to my knowledge.

To quote my former cardio, "It is actually possible to run across the freeway without getting hit."

 

[geebee]

Barry,

Since I am not a pharmicist, I cannot "prescribe" for you. However, I will never skip a dose of coumadin. If I forget a dose, I will take it the minute I realize regardless of when the next dose is due. Since coumadin takes a few days to actually affect the INR, what you do in a 24 hour period is not going to have an instant effect.

I have never forgotten more than 1 dose so I would not know about taking a couple days worth in one swoop. I would probably just double up my dose for the next couple of days.

My INR drops very fast if I skip a dose so that would never work for me.

 

[Karlynn]

In 13 years I have forgotten my dose only a few times. I take my dose in the evening, so I usually go ahead and take it if it's w/in a 12 hour period. Anythink later than that I take a partial dose. I also then wait a week before testing my INR.

 

[Guest]

I know that almost everything says to not double up but I agree with the saying about it's easier to replace blood cells than brain cells. I'd work out some way to get the dose taken.

 

[ALCapshaw2]

A technique I've used is to divide the missed dose by 3 and add that amount to what I take over the next 3 days.

Since I take my Coumadin in the evening (9-10 pm) I usually realize my mistake the next morning. I'm thinking that taking half of the missed dose that morning, with the regular evening dose and repeating that the second day might be an even better approach.

Either way, by the 4 day (including the missed day), you have taken your full dose for that period of time, albeit in a less even distribution. By the 7th or 8th day, everything should be back to normal.

'AL Capshaw'



'AL Capshaw'

 

[tommy]

I alternate 5 mg and 2.5 mg. I missed a 5 mg and noticed it the next morning, So I took 2.5 immediately and then conitnued my normal regimine. I missed 2.5 (10% of weekly dose).

 

[ALCapshaw2]

Barry,

You need to know that there's MORE to Warren's father's story than just missing 4 days of Coumadin. It turned out that he had been MISMANAGED for YEARS with INR's
almost always BELOW the recommended MINIMUM. Those clots may have been forming for a LONG time beforehand and the 4 day miss merely triggered the inevitible.

OTOH, that does NOT mean that there is no risk to missing 4 days. BRIDGE THERAPY with Lovenox or a Heparin Drip (in hospital) is the recommended protocol. A KNOWLEDGABLE Coumadin Clinic Nurse or Doctor needs to manage and monitor the Bridge Therapy.

'AL Capshaw'

 

[Barry]

Al, what's "Bridge Therapy"? Is that when they take you off Warfarin and put you on Heparin before you go under the knife. That's what they did when I had a pacemaker installed.

 

[Ivyplace]

stopping coumadin

stopping coumadin

I am fairly new at this, I had a mitrol Valve St. Jude surgery on Jan 5th of this year, joined the forum and then I had to have a cardio conversion on Feb 3rd- during the two week stay from that, they discovered a large growth on my kidney and I am scheduled for a kidney surgery on March 23rd. Yesterday the doctor told me to stop taking coumadin and on Monday they will admit me to start administring helfin (unsure spelling).

How long does it take coumadin to leave your system? I am more scared of having a blood clot then I am of the surgery.

 

[Barry]

I am fairly new at this, I had a mitrol Valve St. Jude surgery on Jan 5th of this year, joined the forum and then I had to have a cardio conversion on Feb 3rd- during the two week stay from that, they discovered a large growth on my kidney and I am scheduled for a kidney surgery on March 23rd. Yesterday the doctor told me to stop taking coumadin and on Monday they will admit me to start administring helfin (unsure spelling).

How long does it take coumadin to leave your system? I am more scared of having a blood clot then I am of the surgery.

What they've done with me before going back under the knife (for a pacemaker) is continue taking the Warfarin until admission, then put me on Heparin. Does make for a longer hospital stay.

I think Coumadin does stick around for around 3 days, but I'm not sure. Hopefully our resident know-it-all, allodwick, will weigh in on this one.

I'd be scared of possibility of clotting, too. A great aphorism I've run across on these forums in dealing with quandaries like this is, "It's easier to replace blood cells than brain cells."

 

[Ivyplace]

What they've done with me before going back under the knife (for a pacemaker) is continue taking the Warfarin until admission, then put me on Heparin. Does make for a longer hospital stay.

I think Coumadin does stick around for around 3 days, but I'm not sure. Hopefully our resident know-it-all, allodwick, will weigh in on this one.

I'd be scared of possibility of clotting, too. A great aphorism I've run across on these forums in dealing with quandaries like this is, "It's easier to replace blood cells than brain cells."

Thanks Barry, I have called the cardiologist again, the nurse is going to be tired of me, but I do live two hours away from the hospital and asked him again and they claims I SHOULD be ok, don't know if I like the word "Should" but guess I am stuck with it. They did say watch of any swelling in one of my limbs, fingers and if the happens get to the hospital right away.

The next that is going to go wrong with me is an ucler with all this worrying and stress, I don't know anyone around here who has heart problems like me, so this forum is great. I am not the only one after all.

Thanks for responding
Sharon

 

[Barry]

Sharon, I'm new kid on the block around here, too. Spend some time checking out various threads - you'll find tons of useful info. And check out allodwick's web site - pretty sure there's a link to it on each of his posts. He's got tons of info there.

One thing I've learned is that mitral mechanicals (I've got one, too) apparently are the ones most given to throwing clots, so you want to keep your INR on the high side, close to 3.5. Apparently in Europe they go as high as 4.0, not sure about that though.

Best short-term fix for anxiety and worry that I've found is a going for a walk.

Actually, best short-term fix for me was copious quantities of whiskey, but no longer an option now that I'm on Warfarin...

 

[geebee]

Sharon,

I'm going to pipe in here. I am quite alarmed at you stopping coumadin today for an admission next week. If you are anything like most of us, your INR will drop quickly and you will be without a safety net. In addition, the fact that you have a mitral valve is even more dangerous.

I would highly suggest you get in touch with you cardio and fight this decision to stop the coumadin without the protection of Lovenex or Heparin. Even a couple of days could be a problem.

Don't worry about them getting sick of you. If you end up with a clot, you may not be around to get "yelled at".

 

[Ivyplace]

I have another call into the doc, this time I asked to talk to him, not the nurse, so we shall see. if I felt better (kidney is taking a toll on me ) I may not be so nervous, but I feel weak and would like to be stronger for any surgery. My heart is strong however, if fact this is the best my heart has felt in years. No palipations etc.

my husband doesn't really understand all my fears totally, he thinks the Kidney operation is simple compared to the two open hearts I have had. But strokes are on my mind. I did not know that Mitrol valves were more likely to develop clots, but then I never asked. I have a lot to learn yet.

 

[Guest]

Here is my link to bridge therapy http://www.warfarinfo.com/bridgetherapy.htm

 

[ALCapshaw2]

Hey AL,

How about adding the conversion factor for kg to lbs. (1kg =2.2 lbs) or better yet putting the 1mg/2.2 lbs in parenthesis in your Bridging Guide for those of us living between the Big Oceans?

'Al Capshaw'

 

[Barry]

Here is my link to bridge therapy http://www.warfarinfo.com/bridgetherapy.htm

Went to the link. The info is specific to pregnant women and specific to low molecular weight heparin as a bridge therapy.

I dunno what "low molecular weight heparin" is, didn't know there were different kinds of heparin. I presume that "low molecular weight heparin" is a variant, and that when I went in for my pacemaker they put me on crummy old regular heparin to get me off Warfarin before the surgery.

So "bridge therapy" is getting the person off Warfarin and onto heparin before they start cutting on them? If heparin is an anticoagulant, too, why do they do that? I'm thinking that maybe heparin wears off much more quickly than Warfarin, and resumes its therapeutic effect much more quickly, so the window of time during which your INR is lowered can be made as small as possible.

 

[Guest]

OK some day I'll get around to putting the convedrsion factor in.

Lovenox and Fragmin are the two most popular LMWHs. You are right about the short action. They also have to be injecting in the abdomen - causing eggplant belly with their bruises.

 

[Lorraine]

Sometimes when I'm out of my regular daily routine (such as vacation or over night stays at some one elses house for family functions) I have forgotten my Coumadin. As soon as I realize I did, I immediately take it. It's usually less than 10 hours later and so far it hasn't hurt me in the overall picture. More than 12 hours I too, cut the dose some.