Need some help . . . hubby on antibiotics and it's messing with his INR

[Peachy.mom]

Hello everyone! I'm new here, though my hubby and I are not new to heart valves and blood thinners. My mister had his mitral valve replaced in April 2009 and ended up in the hospital for three weeks due to a heparin reaction/allergy. For the most part, his INR has stayed in range, though we have had a few times that it dropped below 2.0 for no apparent reason. That is, until now.

Four weeks ago tomorrow, he was admitted to the hospital with a group B strep infection in his blood. By God's grace, the infection had not reached his heart valve. He was sent home after three days in the hospital and placed on a PICC line and is on penicillin 24-hours/day, as well as two Rifampin orally once/day. The Refampin has wreaked havoc with his INR, making it plunge as low as 1.4. Since he is allergic to heparin, he cannot have the Lovenox shots. His cardiologist's office manages his coumadin, but we had to finally just do what we thought was right . . . they were having him take two large doses of coumadin and then two smaller doses, which didn't make sense ot us because it wasn't helping matters any. He finally just started taking the larger doses (20 mg) everyday. It took two weeks to get him therapeutic. On last Thursday, he was 2.6.

This morning, he had dropped back to 1.6. I am at my wit's end with this. I have a call in to his hematologist and am waiting to hear back from them. Surely there is SOMETHING they can give him besides Lovenox, but if there is, then the cardiologist's office isn't aware of it.

 

[Peachy.mom]

If you are allergic to heparin and have had to deal with low INR, was there something else that you used? I'm really concerned for my husband's safety and refuse to just sit on the sidelines wait for the right dose to be given.

He only has two weeks left on his antibiotics and then we'll be dealing with this again . . . trying to get the dose right so he's not too high.

Thank you!

Julia

 

[Protimenow]

Do you have a meter? If so, while your husband is taking alternating between high doses and low doses (why not just an average of the two daily?), it may make a bit of sense, during this difficult time, to test every two or three days, just to see if these alternating doses are having effects on alternating days. (I'm thinking that perhaps nothing changed since Thursday -- that Thursday, the effect of the high dose was evident, and today, the effect of the lower dose showed up). Leveling out the dosage, rather than going high/low, may help get a handle on the INR. FWIW -- I don't think a 1.6 is a prescription for disaster - but it's certainly advisable to bring the INR above 2.

Don't go nuts with testing more than once or twice a week -- but if it was MY life on the line, I'd try if possible to take the same (or close to the same) dose every day, so that my INR stays stable throughout the week.

 

[Peachy.mom]

Thanks for the reply, Protimenow. We are very thankful to have a meter at home and he is to check it about twice a week until all of this get's resolved.

What you're suggesting does make absolute sense . . . except that he had been taking the exact same dosage every day for over a week when it finally reached 2.6, so we felt positive that we were on the right track. That's why it's frustrating . . . we had decided and told the coumadin clinic that he was going to take the same dosage very day (20 mg) and not going to be going back and forth with it (because it wasn't bringing it up) and they were fine with that . . . and it worked to bring him up to 2.6. They have instructed him to take 30 for the next two days and check again on Wednesday morning. So we shall see . . .

Anyway, Mister's range is supposed to be 2.5-3.5 for the type of valve he has, thus the panic on my part. It's just so darn difficult to get his back up when it falls anyway. It took nearly two weeks in the hospital to get him to 2.0 so he could go home.

Anyway, thank you again very much for the suggestion. We will definitely keep that in mind for those times when he might need to take differing dosages.

Julia

 

[Bina]

Julia, I understood that your husband is taking 20 mg per day, your post was fine.
Could there be something else that is dumping his INR too low...maybe a daily Vitamin pill with K that he has
started? Or maybe a soy based drink like Ensure? It will be helpful to keep a very steady diet while the antibiotic
is wreaking havoc on his INR.

 

[Bina]

Also, the INR today of 1.6 is NOT good, hopefully the docs will call you back today with instructions.

 

[Peachy.mom]

Yeah, I had wondered about his diet, but he really isn't eating anything different . . . or eating differently at all that I can think of. The Pharmasist at the infectious diseases office told him that the rifampin increases ones metabolism, which in turn causes his body to process the coumadin too quickly. This is going on three weeks with him being out of range. Hoping to hear from the hematologist here shortly. The cardiologist's office can deal with the coumadin all they want . . . I'm hoping the hematologist can get him something in place of the Lovenox to protect him while he's having issues.

 

[Protimenow]

Jumping 33 1/3% and expecting to see a change on Wednesday is a bit odd. On Wednesday, you may be some of the effects of the drastically increased dosage -- but Thursday will probably show you a much more significant change in his INR. If you have the luxury of being able to test as much as necessary (realizing that the strips DO cost money), I'd also check on Thursday. I'm just concerned that things may look good on Wednesday, then scary on Thursday. A jump from 20-30 is way beyond dosing suggestions, and I'd worry about the effects on Thursday and Friday. Although you want to get the INR up, I'm not sure that potentially launching hubby above range (which I'm concerned that a move from 140/wk to 210/wk) is the best choice.

Because 20 mg/day brought him into range (for a while, at least), something closer to 20 may bring him back into range, if there was another factor that brought him to 1.6.

I am very interested in how this will play out and hope this change works out fine.

 

[Peachy.mom]

Hey Protimenow . . . I must say that I agree whole-heartedly with you on what you said. I am very concerned about the huge jump in dosing just in case the drop was some fluke and not the meds! The last increase was from 15 to 20 mg . . . I am wondering why such a huge jump this time and not something more conservative, like maybe 25. I would think that they would be a bit more cautious, though I must admit that at times I felt as if they were being too cautious.

 

[yotphix]

Hi Peachy, sorry that you are having trouble with this. To get back to your earlier question regarding alternatives to Lovenox/Heparin, there are alternatives. I have no direct experience with them, and I don't know which if any are appropriate to your husbands particular situation. There is an interesting, though somewhat dense article discussing at least some of the alternatives here, http://www.medscape.com/viewarticle/569831 and a further, also interesting discussion of the need for extraordinary doses of warfarin here http://www.medscape.com/viewarticle/581599 . The second article is interesting in part because it discusses further possible causes. I also have a faint recollection of reading an article recently which discussed the improved efficacy of dosing warfarin at the opposite end of the day from certain other medications. I really don't remember the details but there may be something in that of use to discuss at least. Best of luck with this. I'm sure your guy will pull through it and that if something similar ever happens again you'll be ready and know what to do.

Paul