Most doctors know very little about Coumadin doseage.

[Herb M]

On Friday I was 6.43. The doctor wanted me to stop coumadin for 2 days. I stopped for one day and reduced the doseage on another day. Today I was 3.75. The doctor wanted my to stop 2 more days to lower my INR. I said I would not. The nurse or whoever was giving me the doctors instruction said if I do not lower it, I would bleed. I told her that I was not lowering my dose and will go back to my original dose. She went back to the doctor for further instructions. I was told to check again in a week. I said OK. I will wait 2 weeks before checking again. (I go to the lab for a blood draw).

I seldom get good advice from my doctor, even though she has started a coumadin clinic in her office using one of the figer prick devices. My previos doctor who retired was never worried if I were a little low or high. He just said continue what I was doing. Since the new doctor, who is Ok in all the other areas, I have decided to make my adjustmernts according to the pulished algorithm

 

[Cris N]

I think your approach was logical. The doctor telling you to hold at 3.75 was trying to kill you. You did right.

 

[ALCapshaw2]

Did you Tell this Doctor that you only held for ONE day and took 1/2 dose another which resulted in your drop from 6.43 to 3.75?

If not, you missed a "Teachable Moment". You might also want to show / give her a copy of your Dosing Guide if she is receptive to another "teachable moment". With a non-confrontational approach, she might even become an ally and learn to trust your instincts and guide which would be a Win-Win result.

In hind sight, skipping for 2 days MAY have brought you closer to your range, BUT if I had a 6.43 INR,
I would probably follow your original (more conservative) approach. It brought you into what I consider to be a Safe range (2.0 to 4.0), CLOSE to your target range and avoided putting you at risk for clot formation and a possible Stroke.

With a 3.75 you could simply retest as you chose to did or maybe reduce your dose for ONE Day by 25% or so and retest in 1 or 2 weeks.

'AL C'

 

[catwoman]

On Friday I was 6.43. The doctor wanted me to stop coumadin for 2 days. I stopped for one day and reduced the doseage on another day. Today I was 3.75. The doctor wanted my to stop 2 more days to lower my INR. I said I would not. The nurse or whoever was giving me the doctors instruction said if I do not lower it, I would bleed. I told her that I was not lowering my dose and will go back to my original dose. She went back to the doctor for further instructions. I was told to check again in a week. I said OK. I will wait 2 weeks before checking again. (I go to the lab for a blood draw).

I seldom get good advice from my doctor, even though she has started a coumadin clinic in her office using one of the figer prick devices. My previos doctor who retired was never worried if I were a little low or high. He just said continue what I was doing. Since the new doctor, who is Ok in all the other areas, I have decided to make my adjustmernts according to the pulished algorithm

Herb:

What is your usual dosage? How often having you been having tests?
What do you attribute the 6.43 INR to? (BTW, having the INR measured in hundredths is unnecessary, IMHO.)
What training has your doctor had in anticoagulation management? Is this your cardio or a PCP? What algorithm chart is being used?

I agree with Al, (if I am following the sequence of events correctly) that by not telling the doctor you had not dropped 2 doses, she will think you followed her instructions and that's how you came to a 3.75 INR.

 

[Bill B]

I don't see your doctor's initial recommendation as wrong and hardly different from what you did. However, if you fell from 6.4 to 3.8 by just holding 1-1/2 days dose, then his succeeding recommendation to hold for 2 more days makes no sense at all and I suspect a misunderstanding (see next paragraph). His recommendation to check a week later was reasonable. Why wait 2 weeks? Your INR seems to respond rather rapidly judging by the drop from 6.4 to 3.8 in only 2 days, so you should be at your new "steady state" within a week, as are most people.

6.4 is not a little off. I assume you weren't referring to that when you were talking about not being alarmed if you were a little off. 3.8 is, but I still think it should be brought down into the correct range if it continues at that level. It's not the holding of the dose that is important to achieving this. It's the continuing dosing level. If you resume your previous dose, what's to stop you from going back up to 6.4? Perhaps your doctor meant for you to continue holding 2 doses per week to keep your INR in the proper range. I don't know. It's a bit confusing. I would want to understand if the 6.4 was a fluke or real and why it happened. If you are going to continue on your original dosing schedule then it is being treated as a temporary anomaly. Very strange.

Also, as to published algorithms - these are gross generalizations and not firm guidelines. Warfarin metabolism and the response of clotting factors is complex and variable. These algorithms take almost none of the individual factors into account and they make very broad recommendations that don't satisfy me, but that is the rather poor state of the art right now. Some people are very slow metabolizers, and there is even a genetic marker for this, but it is not in common use yet. I am ridiculously sensitive to warfarin, taking only 1.5mg/day to get into range. If I take even another mg per week, I go out of range. The algorithms do not work for me. My dosing adjustment involves a lot of back and forth between me, the doctor and his coag nurse until we reach a consensus, but I respect their recommendations.

Bill the Pharmacist

 

[Ross]

Bill believe me, we've all been through this same scenario and for most of us, our way of doing things is always better then the Doctors. We have a real good grasp of our needs where they don't. I'm just trying to say, for most of us, leaving dosing up to our doctors can be a mistake.

 

[ALCapshaw2]

Herb,

I'm wondering about your 6.4 INR reading. Was that from a Lab Draw or a Finger Stick Instrument?

Finger Stick Instruments are notorious for reading high when INR is elevated. My Coumadin Clinic did an extensive study to find better instruments and concluded that most have a tendency to read high for elevated INR's. As a result of their testing, they require a Lab Draw for any finger-stick instrument reading above 4.5.

FWIW, I recently had a finger-stick reading of 5.0 from a Coaguchek XS instrument.
The Lab Draw was 4.0 (result returned in <2 hours).
The CRNP's at my clinic have Never recommended a Hold for INR's below 5.0 (to me).

'AL C'

 

[olefin]

Hospital labs can also give different readings on high INR. Once mine tested 6.2, my cardio was 600 miles in another city. He said try another hospital lab, they tested 4.4... was less than an hour difference. He made no change on dosage, week later lab 1 tested 5.0, he then reduced dosage.

I've had 3 cardiologist over the years, the middle one always said hold for 3 days if above 6.0. I would hold for 2 days! Recently on a cruise had diarrhea, INR shot up to 6.1, I stop warfarin for 2 days and reduced dosage 5% until diarrhea passed.
My last cardio turned dosage over to me.

 

[dick0236]

My first reaction is a questionable test (6.4 ?), unless you are having other health issues (flu, diaharea, anti-biotics, etc.). I have also been told that finger stick numbers become more inaccurate as they move further away from the normal ranges (2 to 4). I agree with what you initially did, but I would check weekly until I got back inside my comfort range. My own experience is to make small dosing changes and more frequent INR testing until I get back in my range. Too often, medical people make changes that lead to the dreaded "roller-coaster"

 

[Herb M]

It is always a doctords assistant that calls me about my reading. I am not sure that she is even a nurse.

I always use the hospital labfor my draws, no finger procks.

I did tell the caller what adjustment I made.

The high reading was propably due to an episode pf vomiting and diarrhea.

I have learned that my adjustments are better than that given to me my the doctor's office.

I have been on coumadin for 22 years and will not be put at risk by a doctor's advice.

 

[Philip B]

22 Years

22 Years

Hi Herb,

If you've been successfully managing your coumadin for 22 years, I'd tend to believe that you probably know what you're doing. Has your doctor been a doctor for 22 years?

-Philip

 

[Bill B]

Yeah, Herb, 22 years should give you some credibility. Not knowing how long you'd been on warfarin, I couldn't tell if the 6.4 was an anomaly. But your doctor and nurses should know your history well enough to have made the correct assessment. I don't think there was anything wrong with the initial response, as I said, but after that their recommendation got very weird. I know there is a strong feeling around here not to trust doctors with warfarin therapy. Who knows, I may not end up trusting mine, but so far he is pretty good and the coag nurses are good with possibly one exception I ran into today. I spent most of my time in healthcare in academic medical centers working with many of the best doctors and nurses, so I have a lot of faith in them, and I may have some advantages being able to select good doctors because I speak their language and am still basically in a medical mecca (SF Bay area). That said, I will tell you that from my perspective, the management of warfarin, a rather dangerous drug, has not progressed one iota in 30 years. The protocol approach is primitive and fraught with potential pitfalls. No wonder everyone thinks they can do it better themselves, myself included. Other drugs that have such low therapeutic margins (ratio of toxic to therapeutic dose) now have much more rigorous methods of establishing and maintaining the correct dose level. When I started to look all this over again last year as I started therapy, I expected a lot more science would be applied. Boy, was I disappointed.

Carry on.

Bill

Oh, and it's real bad when an untrained office assistant relays the doctor's recommendations. Today I had a new nurse call me, and it was clear she was rather rigidly interpreting some notes that were not quite right about my INR target values. I tried to have a fair discussion with her, but we ended up in some disagreement, perhaps like you did. At least she agreed I could do what I wanted to, but I could tell she wasn't all there, unlike the other nurses I have dealt with. Anway, I don't want to end up getting classified as a "bad patient", so I will explain it to the doctor next time I am in and see if he can fix the misleading note. He seems to respect my input, as your doctor should based on your rather remarkably long experience.

 

[Ross]

That said, I will tell you that from my perspective, the management of warfarin, a rather dangerous drug, has not progressed one iota in 30 years. The protocol approach is primitive and fraught with potential pitfalls. No wonder everyone thinks they can do it better themselves, myself included. Other drugs that have such low therapeutic margins (ratio of toxic to therapeutic dose) now have much more rigorous methods of establishing and maintaining the correct dose level. When I started to look all this over again last year as I started therapy, I expected a lot more science would be applied. Boy, was I disappointed.

The problem is, the drug has been around for 50 years and you cannot get the same answer from every doctor you talk too. Your darn lucky if you have one that actually knows how to dose the drug. There is NO EXCUSE for this. We see it day in and day out in this forum. I'd say a good 88 to 90% of the people that come in here, have clueless managers and in many cases, doctors too. I mean come on, there are protocols and algorithms in place. Do any of them even read?

One thing you said bothers me, while it may be true, "warfarin, a rather dangerous drug". I think you should say Potentially dangerous drug. This drug and it's dangers would drastically decrease if the medical community would get their head out of their shorts and start getting it right.

 

[dick0236]

For those who are new to warfarin or may soon go on the drug, I also take exception that warfarin is "a dangerous drug". That implies that the drug should be feared Personaly, I have found the drug to be very predictable IF it is taken as prescribed, tested routinely and using a little common sense. I am not diabetic, but it is my impression that the day to day monitoring of insulin level is more of a hassle than INR monitoring. A few years ago, when I was a young man in my 60s, I went to a large INR clinic for testing. I noticed that there were a lot of "old people" waiting for testing. I learned that very few valve patients were among them. Warfarin is used for many problems and a great many of the patients are "geriatric". Unfortunately, many of them can"t or won't maintain the simple routine necessary to manage warfarin. It is my belief that warfarin management has come a long way since the "olden days" (been there, done that), but the patient has to take an active role while on the drug.

 

[Bill B]

One thing you said bothers me, while it may be true, "warfarin, a rather dangerous drug". I think you should say Potentially dangerous drug. This drug and it's dangers would drastically decrease if the medical community would get their head out of their shorts and start getting it right.

Hey Ross:

There are drugs that have a narrow therapeutic margin, and warfarin is one of them. Yes, it can be managed safely, but it is inherently on the problematic end of drugs with essentially a 2 or 3:1 safety margin. Some drugs have a 1000:1 margin or more. Very hard to get into any kind of potentially fatal problems with them. That's all I meant. Yes, most patients do well for very long periods with proper monitoring, but many also get into some trouble with excessive bleeding at some point over the long haul. It's pitiful if a doctor, especially a cardiologist, or coag nurse doesn't have good familiarity with the warfarin dosing protocols and the things that affect warfarin, but even with that I think we are still in the relative dark ages with understanding warfarin. Like you said, it's been around 50 years, but almost nothing has changed in that time. Maybe that's partially why doctors seem so ignorant. I will say that I looked at some dosing protocols last year and basically tossed them aside because I found them so useless. I asked my friends who are still in the cardiac health business for their protocols and was stunned to get back the same over-generalizations. Not one iota of new science. Still, everyone needs to have a set of reasonable rules they follow to make adjustments and respond to anomalies, and it appears the overwhelming experience here is the medical community does not. Anyway, I've been mulling this over for while, hoping to come up with some better ideas, but the science just isn't there. If Herb can make it 22 years under these conditions without a major problem and only the occasional fight with his care providers, I guess that's pretty good and I just have to learn to roll with it.

I guess the word "dangerous" is too provocative here, but that's my perspective as someone trained in the field. I'm not afraid at all of drugs that are called dangerous if I understand how they work and how to manage them. I'm just cautious, as all of you are with your warfarin. When I was making my decision about mechanical vs. bio, the potential hazards of warfarin were a relatively minor consideration. I felt pretty confident that with careful monitoring I would be OK, even though there are some data on bleeding complications, particularly in more elderly patients, that might scare some people. Anyway, I think we probably share the same attitude towards warfarin despite the way I refer to it. After all, I'm on it too.

 

[Ross]

Simple dosing, so easy a caveman can do it. If your too low, increase the dose by 10% for the week and test again in one week. If your too high, lower the dose by 10% and test again in one week. Follow this principle and it won't be long until your dead on spot and stable. Now tell me, why can't doctors get it? I'm still seeing major name players giving poor and bad advice concerning diets, dosing, activities and the list goes on and on. I mean really, how hard is that?

I guarantee most of the bad events that occur are because someones managed improperly. Heck, have an emergency situation and it's like a Chinese fire drill with everyone arguing about what should or shouldn't be done. Again, there is no reason for it.

 

[Bina]

I am another low doser, like Bill. My weekly total is 18 mg and maybe once per year a 5% dose change may be needed.
Some of us can't use the dosing charts for this reason, and have better results with diet changes.
Even though I am sensitive to meds, I don't fear Coumadin at all....maybe because I have seen people do alot more damage to themselves with lesser meds and even OTC products. Coumadin is my friend. Beta Blockers are another story...Grrrr.

 

[catwoman]

Simple dosing, so easy a caveman can do it. If your too low, increase the dose by 10% for the week and test again in one week. If your too high, lower the dose by 10% and test again in one week. Follow this principle and it won't be long until your dead on spot and stable. Now tell me, why can't doctors get it? I'm still seeing major name players giving poor and bad advice concerning diets, dosing, activities and the list goes on and on. I mean really, how hard is that?

Ross:

Many people are mathematically challenged. I'll say fortunately mathematically challenged, because they ensure that my husband has a job working with remedial math students on the junior college level. ) He has a T-shirt that says "4 out of 3 people can't do fractions"

Seriously, it ISN'T hard to figure out, if you use a calculator. Working with percentages is far easier than the dosing charts that say to drop a tablet or half tablet. I split 10s and 1s to get 5.5mg, and dropping a tablet would spin my mathematically challenged head around.

 

[Ross]

Ross:

Many people are mathematically challenged. I'll say fortunately mathematically challenged, because they ensure that my husband has a job working with remedial math students on the junior college level. ) He has a T-shirt that says "4 out of 3 people can't do fractions"

Seriously, it ISN'T hard to figure out, if you use a calculator. Working with percentages is far easier than the dosing charts that say to drop a tablet or half tablet. I split 10s and 1s to get 5.5mg, and dropping a tablet would spin my mathematically challenged head around.

Are you suggesting a Mathematics 101 thread?

 

[Bill B]

Simple dosing, so easy a caveman can do it. If your too low, increase the dose by 10% for the week and test again in one week. If your too high, lower the dose by 10% and test again in one week. Follow this principle and it won't be long until your dead on spot and stable. Now tell me, why can't doctors get it? I'm still seeing major name players giving poor and bad advice concerning diets, dosing, activities and the list goes on and on. I mean really, how hard is that?

I guarantee most of the bad events that occur are because someones managed improperly. Heck, have an emergency situation and it's like a Chinese fire drill with everyone arguing about what should or shouldn't be done. Again, there is no reason for it.

Ross: I started to write out a lengthy response that would probably only interest me. I'll just say that if you have a system that works for you and others here, that's great. It wouldn't work for me. A 10% per week adjustment would have left me way off the mark for months. A relatively simple method to calculate warfarin's metabolic rate and rate of change of INR from a single dose could save all the fiddling that goes on initially. You'd need 2 warfarin levels after a single dose and TWO INR's (done about 24 hours apart), not one as is done now. I did it with theophylline, a drug used for asthma that also has a 2:1 therapeutic margin, and published the technique. It saved a lot of time and trouble figuring out theophylline doses. I appreciate that you and many people here seem to have had so few problems with warfarin that this all may sound completely unnecessary and just a mental exercise for people like me. So be it. Truthfully I haven't had any trouble with warfarin, but I think it took too long to arrive at the right dose for me and may put some people at risk, and a little more information gathered initially could change that. We ended up applying this idea to several drugs in the hospital and it save a lot of time, aggravation and helped to avoid unnecessary toxicity.

Anway, I'm getting way off the mark. I think we agree that the doctors and nurses have some trouble with this.