Need dosing help...

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halleyg

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591
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Atlanta, GA
Just when I thought I had this all figured out... been really steady lately with my INR. Two weeks ago was 3.6 and was happy w/that. Then today I was 2.4 (low side for me, since I have a MV) They have a new dosing nurse now and she didn't seem to know how to dose me. I take 7.5 mg 6 days/week, 10 mg/1 day. She said take 10 mg an extra day. I was pretty OK with that, but then tonight went to take my warfarin and realized last nights dose was still in the box! So I am low and missing a dose. Not sure what to do? Tonight is the night I take 10, took it but wondering if I should add 2.5 before I go to bed.. not sure at all. Having lots of afib stuff lately so more worried than usual.
 
JMO - take the 10mg tonight then take 8mg for 7 days and retest

I used the dosing calculator (http://www.pace-med-apps.com/CoumCalc.htm), I just used your last INR reading of 2.4. It says to increase 5% for 7 days then retest.

2.4 is 'just off' the mark so just a small tweak is all you need.

I wouldn't worry about taking the 2.5mg. The 10mg tonight really won't show up in any test until maybe Sunday and you don't want to start a roller-coaster ride.
 
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Hi Halley,

I think taking 2.5 tonight would be ok, then if tomorrow is a 7.5 day, add 2.5 to that dose too. Bina is good at this stuff and so is Al Capshaw so hopefully they'll be along soon.
 
JMO - take the 10mg tonight then take 8mg for 7 days and retest

I used the dosing calculator (http://www.pace-med-apps.com/CoumCalc.htm), I just used your last INR reading of 2.4. It says to increase 5% for 7 days then retest.

I wouldn't worry about taking the 2.5mg. The 10mg tonight really won't show up in any test until maybe Sunday and you don't want to start a roller-coaster ride.


Thank you for this link Freddie, I may need it someday myself.
 
Thanks both of you for the help, and thanks for that link Freddie. Although I appreciate it even more that you figured it out for me, the calculator was confusing b/c my dose isn't the same every day and I came out with a different number, but sure I didn't do it right! I am more worried about the missing dose affecting the current reading of 2.4. In over three years I have never missed a dose, I know it takes a couple of days to show so wondering if tomorrow I would be even lower, even though I took 10 tonight? Being the scaredy cat I am, I probably will add the 2.5.
 
You don't test everyday do you?

When I missed a dose and fell to 1.5, I was increased than more than 10% - I was on a roller-coaster ride for months.

Also, when you use the dosing calculator, use the second section called "Continued Dosing:"
 
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IF you truly missed your Tuesday evening dose, I suspect that would show up by Thursday or certainly by Friday so my recommendation is to retest either Thursday or Friday and then reassess your dosing. Addiing an extra amount due to already being (slightly) low would most likely just confuse the matter.
If you are nervous, test Thursday and see where you are. As long as you are over 2.0, you *should* be OK for several days and can adjust appropriately to bring you back above 2.5 by next week.

Alternatively, if you are ABSOLUTELY CERTAIN that you missed your Tuesday dose, you could split one pill and take 1/2 each morning for the next 2 days. That's what I would if I was CERTAIN I had missed a dose. Most managers probably would not use that method.

Try not to get overstressed. Most Self Dosers feel safe as long as their INR is somewhere between 2 and 4 and they get back to their target range in a week or so. IF your INR drops below 2.0, then you can consider asking about Lovenox Injections to tide you over until your INR is back in range. But again, as long as you don't stay low for more than a few days you should be OK.

Hope I haven't confused you too much.

'AL C'
 
It may be easier to calculate your dosage if you consider your WEEKLY dosage, rather than what you take each day. This way, if you decide to change your dosage, it would probably be easier to figure out what changes you may want to make and, if necessary, to spread them out during the week, and still hit your target. (In my case, I was taking 51.5/week, but my INR seemed to go a bit higher than desirable - but only slightly out of range. This corresponded to 7 mg six days and 10 mg the seventh day. I dropped it to 49 - and the drop was easy -- 7 mg every day). Basing your changes on a weekly dose really seems to make it easier to handle - and to calculate - dosage changes. In your case, you're taking 62.5 mg/week. From that, it's easy to figure that a 5% increase would be an additional 3 mg/week (probably a 7.5 mg plus a 1 mg pill three days a week (MWF?) and a 7.5 mg pill the alternating three days a week(TuThSa?), with a 10 mg one day(Su?), or a 10% increase would be 6 mg (ignoring the 2.5 mg) - or 7.5 mg plus 1 mg for six days and 10mg on a seventh day. I'm not suggesting that this is what you should do - you should check with your physician or clinic -- I'm only showing this as an example of how to calculate your weekly dosage and how to calculate increases. Doing it this way makes it fairly easy to make changes.

In order to be sure you got your daily dose, it may be worthwhile to invest in a seven day pill holder. Put each daily dose in the appropriate compartment. This way, you should be able to see at a glance if you missed a dose, and can then respond appropriately.
 
IF you truly missed your Tuesday evening dose, I suspect that would show up by Thursday or certainly by Friday so my recommendation is to retest either Thursday or Friday and then reassess your dosing. Addiing an extra amount due to already being (slightly) low would most likely just confuse the matter.
If you are nervous, test Thursday and see where you are. As long as you are over 2.0, you *should* be OK for several days and can adjust appropriately to bring you back above 2.5 by next week.

Alternatively, if you are ABSOLUTELY CERTAIN that you missed your Tuesday dose, you could split one pill and take 1/2 each morning for the next 2 days. That's what I would if I was CERTAIN I had missed a dose. Most managers probably would not use that method.

Try not to get overstressed. Most Self Dosers feel safe as long as their INR is somewhere between 2 and 4 and they get back to their target range in a week or so. IF your INR drops below 2.0, then you can consider asking about Lovenox Injections to tide you over until your INR is back in range. But again, as long as you don't stay low for more than a few days you should be OK.

Hope I haven't confused you too much.

'AL C'

No, you haven't, I do feel comfortable with the advice of taking 1/2 each morning. I am absolutely certain I missed since the pill was still in my pill box. Thanks a lot for your help, I have called the nurse I used to use who knew what she was doing, so hopefully she'll call me back soon and I can get tested again sooner than two weeks.
 
It may be easier to calculate your dosage if you consider your WEEKLY dosage, rather than what you take each day. This way, if you decide to change your dosage, it would probably be easier to figure out what changes you may want to make and, if necessary, to spread them out during the week, and still hit your target. (In my case, I was taking 51.5/week, but my INR seemed to go a bit higher than desirable - but only slightly out of range. This corresponded to 7 mg six days and 10 mg the seventh day. I dropped it to 49 - and the drop was easy -- 7 mg every day). Basing your changes on a weekly dose really seems to make it easier to handle - and to calculate - dosage changes. In your case, you're taking 62.5 mg/week. From that, it's easy to figure that a 5% increase would be an additional 3 mg/week (probably a 7.5 mg plus a 1 mg pill three days a week (MWF?) and a 7.5 mg pill the alternating three days a week(TuThSa?), with a 10 mg one day(Su?), or a 10% increase would be 6 mg (ignoring the 2.5 mg) - or 7.5 mg plus 1 mg for six days and 10mg on a seventh day. I'm not suggesting that this is what you should do - you should check with your physician or clinic -- I'm only showing this as an example of how to calculate your weekly dosage and how to calculate increases. Doing it this way makes it fairly easy to make changes.

In order to be sure you got your daily dose, it may be worthwhile to invest in a seven day pill holder. Put each daily dose in the appropriate compartment. This way, you should be able to see at a glance if you missed a dose, and can then respond appropriately.

Thank you, I appreciate the explanation! I think I understand now. I was pretty tired last night and my brain couldn't take anymore information LOL. I do have the 7 day pill box, which is how I knew I missed the night before.
 
Update: I was able to get in touch with the dosing nurse who knows what she's doing. She thinks I was already starting to drop b/c of that missed dose. I have a history of dropping like a rock if I leave off a dose (which I did in the past per dr. orders then ended up in the hospital with my INR in the 1's) I'm not even supposed to bridge w/o being in the hospital b/c of this. Wasn't even thinking of this, have been so steady for a while now. She said no biggie about adding the 2.5 last night since I'm dealing with the afib too, and to test again next week. Thanks again all for your feedback and advice.
 
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