Need guidance re Warfarin Dosage

[Eva]

My INR has been 2.6 for several weeks, and now it is 2.1 since Wednesday, but I just got the results now. My doctor left the office thinking I am fine without changing the dosage! Please guide me to how much I should elevate my dosage to be in range (2.5-3.5).

I have been taking 7 mg Warfarin for several weeks. My food has been the same...I may have drunk more orange juice this week than usual.

I started 20 mg Simvastatin (Zocor) on 12/31/08 nightly
Other Mediication which has been the same since surgery: Coreg 12.5 mg/day, Synthroid .112/day (3 days/week), Synthroid .125 (4 days/week).

Thanks in advance

 

[Rich]

Eva,
I don't know if the Zocor or the orange juice has any effect on your INR.
Personally I would add 3.5mg per week. Just snap a pill in half, add it to your weekly dosage and see what happens.
Rich

 

[Lynlw]

IF it is taking you 2 days to get your results they really aren't doing you much good. Do you normally have to wait this long?

 

[Eva]

IF it is taking you 2 days to get your results they really aren't doing you much good. Do you normally have to wait this long?

Unfortunately, yes, Lyn, and this is why I cannot wait to receive my own home monitor.

Thanks.

 

[Bina]

Hi Eva,
I agree with Rich, the simplest is add half a pill tonight. (3.5) which is a 7% increase for the week.
A good plan would be to test again in 4-5 days and see where you are at.

 

[ALCapshaw2]

My INR has been 2.6 for several weeks, and now it is 2.1 since Wednesday, but I just got the results now. My doctor left the office thinking I am fine without changing the dosage! Please guide me to how much I should elevate my dosage to be in range (2.5-3.5).

I have been taking 7 mg Warfarin for several weeks. My food has been the same...I may have drunk more orange juice this week than usual.

I started 20 mg Simvastatin (Zocor) on 12/31/08 nightly
Other Mediication which has been the same since surgery: Coreg 12.5 mg/day, Synthroid .112/day (3 days/week), Synthroid .125 (4 days/week).

Thanks in advance

From Al Lodwick's Dosing Chart (see www.warfarinfo.com) for a desired INR of 2.5 to 3.5

"For an INR of 2.1 to 2.4:
Increase *weekly* dose by 10-15%.
Recheck in 1 week."

Talk with your Cardiologist *and* whoever is managing your Coumadin / Warfarin about the 2 day delay in getting your results. That is simply NOT Acceptable!

'AL Capshaw'

 

[Eva]

Thanks, Rich, Bina and Al for your answers.

Someone from my doctor's office just called me and her recommendation is to take 10mg tonight and tomorrow and Sunday and go for blood work on Monday. This is way higher than all of your and Al's recommendations!

Any comments?!

 

[zipper2]

Good advice given Eva,sure hope you get your machine
frustrating when it takes so long for a call back on inr's
been there and done that....good luck

zipper2(DEB)

 

[Freddie]

3 hours.........that's all the time you should have to wait for results. Next time you talk to your doctor tell him/her so...........2 days is unacceptable.

 

[Lynlw]

Eva, is there any place else you can go until you get your machine? Basically they are now telling you what to do based on your bloodwork 2 days ago, who knows what your INR is today. I'd defniately call and find out why you can't get reults the same day.
I can't help you on the dosage, BUt IF it were me personally I would go with Al's recs over a doctor that doesn't mind you waitng days for test results. I think it seems like a pretty high increase

 

[Bina]

When I was lab testing we had the following arrangement for the more "stable" clients.
Blood was shipped, yes shipped, in the a.m.
Any test results out of range were called in to doctor same day.
All test results in range were sent off in the mail....2 day delivery.
The thing was that I was always sitting by the phone on blood test day in case the results were low and my doc would call.
I got fed up with that real quick!!

 

[Rich]

Eva,
I agree that sounds like a large increase, it may put you on the 'roller coaster'.
From what you said that comes to aproximately a twenty percent increase to your weekly dosage. Since you are not that far out of range, it does sound like a little too much. How are you going to take 10mg if your pills are 7's. Does this mean a new prescription?
Personally I would add an extra 3.5mg twice a week at the most, and then get tested after about a week.
I also agree with the others, two days for your results is ridiculous.
I always get mine within hours of testing.
Rich

 

[Bina]

Thanks, Rich, Bina and Al for your answers.

Someone from my doctor's office just called me and her recommendation is to take 10mg tonight and tomorrow and Sunday and go for blood work on Monday. This is way higher than all of your and Al's recommendations!

Any comments?!

Like Rich said: This is a big increase which could send you too high.
Today's dose (friday) will show up on Monday's blood test, the Saturday and Sunday doses won't show.
We had a couple of members report that Simvastatin has actually raised their INRs so be careful and test more often.

 

[ALCapshaw2]

Thanks, Rich, Bina and Al for your answers.

Someone from my doctor's office just called me and her recommendation is to take 10mg tonight and tomorrow and Sunday and go for blood work on Monday. This is way higher than all of your and Al's recommendations!

Any comments?!

In my *opinion* whoever gave those instructions is CLUELESS about how Coumadin works.

They want you to increase your daily dose by 43% for 3 days and test on the 4th day.

First, the 43% increase is a GREAT WAY to put you on a Rollercoaster Ride from which you may never return to normal with future instructions based on this kind of ignorance.

Second, testing after 4 days when you have increased your dose during the 3 previous days will NOT reflect the full effect of the Coumadin which takes 3 or 4 days to become fully metabolized. In other words, the effect of the last 2 days certainly will NOT be reflected in the test on day 4.

Third, IF they recommend a change after the test on day 4, it will likely cascade the effects due to the not-yet-fully metabolized doses you took on day 2 and 3.

Personally, I would FIRE whoever gave you those instructions.

FWIW, whenever I am slightly out of range my Coumadin Clinic Nurse and I discuss whether to change my WEEKLY dose by a *small* amount (4 to 8%)! Brings me in every time.

Hopefully some other self-dosers will chime in or you can also check the American Association of Family Practicioneers (AAFP) guidelines which Ross often provides a link to and see how they compare with Al Lodwick's guideline. (MY Coumadin Clinic guidelines follow very close to Al Lodwick's).

I know this puts you between a Rock and a Hard Place:
Choose between what some guy on the internet said (based on AL Lodwick's Dosing Guide)
or do what your Doctor's Office person (whoever that is and with whatever background).

I would want to know exactly WHO gave those directions. IF they came from your Doctor, you might want to find a new Doctor! If they came from his nurse or someone in his office, the Doctor needs to know what foolishness his office staff is passing out.

Again, I would follow Al Lodwick's guidelines, re-test next week, and when you are in-range tell them how you got there (and hope your Doc doesn't get too P.O.'d)

 

[CThrock]

Eva,
I just got my INR checked on Monday, they called me the next day and told me it was 2.3 and to up my dose to 3.5 one day a week and recheck in one week.
I take 7.5 mg M,W,F and 10mg on T,Th,S,Sun. So I will take 10mg on Fri too with the change.
I agree with added 3.5 to your week. That sounds pretty safe to me.
I don't feel you should have to wait that long to get your results. Even my next day is too long. That's why I'm happy to be getting the monitor.
Keep us posted on what you decide.
Hope that helps.
Crystal

 

[njean]

Gosh Eva,

I'm so sorry you're going thru this frustration! I can remember when I had to lab test & then the lab had to send the report to my doctor & half the time they'd forget to fax it, etc, etc. I went thru so much stress the year right after my 3rd OHS it's unbelievable! -- something that patients like us DO NOT need! That's why I was so relieved when I finally got my monitor.

And I agree that you should increase it by just 3.5 mg & recheck in a week.

Good luck my friend & I hope you can get your home tester real soon!

 

[Eva]

.....frustrating when it takes so long for a call back on inr's been there and done that..
Yes, it is frustrating, Deb, and I can't imagine what you had gone through when you stopped your warfarin and surgery was cancelled! God bless your heart.

3 hours...that's all the time you should have to wait for results.

Unfortunately he himself has to send the blood to the main UCLA lab downtown

Eva, is there any place else you can go until you get your machine? Basically they are now telling you what to do based on your bloodwork 2 days ago, who knows what your INR is today. This is actually what I thought of too, Lyn when they called...I am OK now and I know I shall survive this through the advice of awsome friends with experience on this on this forum and through awsome friends's support like you.....

When I was lab testing we had the following arrangement for the more "stable" clients. Blood was shipped, My blood goes through snail mail...it is sent by a courrier to the main lab which is 45 mins. away, but who knows to how many other places the courrier goes to before the final destination!

Eva,
I agree that sounds like a large increase, it may put you on the 'roller coaster' or makes me swim in my own blood, God forbids.........How are you going to take 10mg if your pills are 7's. last time the pharmacy did not have the 7mgs, so I requested 6mgs and 1mgs .........Personally I would add an extra 3.5mg twice a week at the most, and then get tested after about a week. Will do that

.....We had a couple of members report that Simvastatin has actually raised their INRs so be careful and test more often.Thanks, Bina, I shall watch out

......increase is a GREAT WAY to put you on a Rollercoaster Ride from which you may never return to normal with future instructions based on this kind of ignorance.I agree and I am so happy that you all are here for all of us...this is a blessing

.....you can also check the American Association of Family Practicioneers (AAFP) guidelines I did, their recommendation is between 5-15% if INR is between 2-2.4
......
I would want to know exactly WHO gave those directions.
Again, I would follow Al Lodwick's guidelines, re-test next week, and when you are in-range tell them how you got there (and hope your Doc doesn't get too P.O.'d)I took 10.5mg tonight, will go back to 7mg tomorrow and maybe 8mg Sunday, Monday, and Tuesday?!

Eva,
I just got my INR checked on Monday, they called me the next day and told me it was 2.3 and to up my dose to 3.5 one day a week ....Hope that helps.
Thanks, Crystal, it is always helpful to get each other's support

Gosh Eva,

I'm so sorry you're going thru this frustration! I went thru so much stress the year right after my 3rd OHS it's unbelievable! -- something that patients like us DO NOT need! That's why I was so relieved when I finally got my monitor.Thanks, Norma, I really do not need this extra tension indeed! I am looking forward to the day my insurance approves my request for hometesting.

 

[ALCapshaw2]

Eva wrote: "I took 10.5mg tonight, will go back to 7mg tomorrow and maybe 8mg Sunday, Monday, and Tuesday?!"

At 7 mg/day, your weekly dose comes to 49 mg.
5% of 49 mg is 2.5 mg, 10% of 49 mg is 5 mg, and 15%
of 49 mg is 7.5 mg.

The 3.5 mg extra that you took represents a 7% increase.
That *may* be enough to get you back in range in 4 days (by itself, i.e. going back to 7 mg/day) if you are a person who responds to small doses (as many do), or you may want to take an extra 1 mg per day for 3 days (for a total increase of 6.5 mg which would get you to almost 15%.

If you stick with the 3.5 mg increase ONLY, you could retest in 4 days to see where you are. If you continue with an extra 1 mg per day for 3 days, you will want to wait 6 or 7 days before retesting. You may also want to contact your DOCTOR, tell him about the recommendation from his office staff, tell him what you did, and ask what HE wants you to do. I HOPE he gives his staff some 'education' on proper dosing!

'AL Capshaw'

 

[Eva]

Eva wrote: "I took 10.5mg tonight, will go back to 7mg tomorrow and maybe 8mg Sunday, Monday, and Tuesday?!"

At 7 mg/day, your weekly dose comes to 49 mg.
5% of 49 mg is 2.5 mg, 10% of 49 mg is 5 mg, and 15%
of 49 mg is 7.5 mg.

The 3.5 mg extra that you took represents a 7% increase.
That *may* be enough to get you back in range in 4 days (by itself, i.e. going back to 7 mg/day) if you are a person who responds to small doses (as many do), or you may want to take an extra 1 mg per day for 3 days (for a total increase of 6.5 mg which would get you to almost 15%.

If you stick with the 3.5 mg increase ONLY, you could retest in 4 days to see where you are. If you continue with an extra 1 mg per day for 3 days, you will want to wait 6 or 7 days before retesting. You may also want to contact your DOCTOR, tell him about the recommendation from his office staff, tell him what you did, and ask what HE wants you to do. I HOPE he gives his staff some 'education' on proper dosing!

'AL Capshaw'

Al,

Many thanks. I shall stick to the 3.5mg increase I took yesterday and retest on Monday, as I do normally respond to small doses to medication in general. Will definitely talk to my doctor and verify the person who called me, as I never heard of her nor saw her before. I am assuming she works for one of the other doctors in the same office and that was that doctor's recommendation since my doctor was gone for the day when I got the results, unless she spoke to him on the phone. Will find out Monday.

Thanks again. I was able to take a deep breath before going to bed yesterday

 

[Ross]

I wouldn't do anything to your dose. I'd leave it alone. If you started Zocor, your INR is going to rise without a dose adjustment.

1 potential interaction was found for the drugs you selected.
You searched for interactions between the following drugs :

Coumadin Tablets
Zocor


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(Note: Not all drug interactions are known or reported in the literature, and new drug interactions are continually being reported. This information is provided only for your education and for you to discuss with your personal healthcare provider. )

WARFARIN SODIUM (in Coumadin Tablets) may interact with SIMVASTATIN (in Zocor)

Simvastatin may block the breakdown of warfarin by the liver. If this happens, blood levels of warfarin could be increased and this could increase its anticoagulant effect. Warfarin is generally used to prevent your blood from "coagulating" or forming blood clots. When simvastatin and warfarin are used at the same time, your blood may be much less likely to clot and this may increase the risk of excessive bleeding. If these drugs are taken together, your doctor may want to monitor you closely when therapy with simvastatin is either started or stopped. Blood tests can be used to make sure that you are getting the right amount of warfarin. If you are experiencing problems, it may be necessary to adjust the dose of warfarin.Discuss this potential interaction with your healthcare provider at your next appointment, or sooner if you think you are having problems.

This interaction is well-documented and is considered moderate in severity.

Last Updated:August 2006