New INR Level Recommendations???

[Georgia]

Help!

Hey, Al! Got my inr checked today - 3.4 (last time it was 2.9). Was darned happy. Then the nurse said that the heart docs sent new recommendations for all patients lowering recommended levels to a maximum of 3.2; and you can guess the rest (yep - lower my warfarin dose 1 mg per day - I'm taking 4.5 mgs. per day). I told them I wanted to talk to cardiologist first. Pretty well irritated the nurse. But this pretty well irritated me. My feeling is that even if there is such a change for heart valvers, they shouldn't lower the dosage so much.

Haven't seen anything about new recommendations - how about you??

 

[Ross]

These are the new recommendations.

These are the new recommendations.

http://www.onevalveforlife.com/ovflTemplate/ovflContentTmp.aspx?section=1&page=3#accaha

Nothing new since July 2000 to my knowledge.

I agree that your being dropped too low in dosage, but what do I know anyway?

 

[Nancy]

Thank you for posting that link, Ross. I took a look at the elective surgery info. which we're always talking about here. There are some variables there.

Just looking at the site, Joe has several mitigating factors, a mitral mechanical, an aortic mechanical and chronic afib.

So each patient is a little different.

 

[Ross]

As Al has said before, "They are just guidelines, nothing set in stone."

 

[ALCapshaw2]

Your intuition is 'right on' Georgia !

First, 3.4 vs 3.2 is NOT a large difference and may well be within normal testing tolerances in which case it may not be wise to make any change at all.

Second, IF a change is called for, the 10% Guideline states that if INR is too high, reduce the WEEKLY total of Coumadin by 10%.

At 4.5 mg a day, you are taking 31.5 mg/week.
10% of 31.5 is 3.15 mg so your new total should
be 28.35 mg / week which is 4.05 mg / day.
Round off to 4.0 mg/day.

(You should confirm this with your Cardiologist
or Coumadin Clinic. Ask your nurse if she is
using the "10% solution" as her guideline.
If not, why not?)

'AL'

 

[LUVMyBirman]

Keep my INR at or around 3.5. I will not change. Better safe than sorry! Also agree with Ross and Al. 1mg is drastic. My guess is 1/2 mg daily would do the trick. Please talk to your doctor Georgia.

 

[Rich]

Georgia,
I think Al hit it right on the head.
That big of a reduction just doesn't make sense.

 

[EVELYN]

Gina.....I absolutely agree with you on the 3.5......I'd rather Tyce be a bit on the up side than the down. We've had NO noticeable difference with 3.5 or .6., .7,.8, or.9, so we don't get "Crazy" any more. We follow the 10% and go from there......thanks to everyone on this site and especially MR. AL.

Georgia, girlfriend, you'd better set those people straight-----imho they know not what they speak!!! Call that cardio and see what he/she says.

I LOVE THIS SITE!!!

Ev

 

[Les]

This is where I get confused.....if I even hit 3.0, my doc goes nuts and I get the standard lecture about 'brain bleeds", etc. yada-yada-yada.....So, for ten years now, I average 2.8. I only test once a month and I'm on target most of the time...other than those times I'm a bit up, (which I prefer.) I tell the doc, "Hey, I'm still healthy...don't wear Kevlar gloves when working on the car, have cut myself shaving 1,000 times, and my wife will attest that if I don't bleed at least once during any home project, then I must not be doing it right." I think anyone could be tested once every hour and there would be some "drift" in each result.
Maintaining consistency with diet and exercise is the only way we have to maintain at least some INR control...I just wish there was a standard that ALL docs understood. We are in control of our destiny, but the medical professionals have to provide accurate information!
__________________
Les AVR '93 / '95
"Still Alive And Well"

 

[Georgia]

A-ha! The plot thickens . . .

A-ha! The plot thickens . . .

So - I spoke to my cardiologist's PA; she called back and said that neither my cardio nor the president of the heart docs institute knew anything about a letter sent to my pcp with a change in the blanket advisory about the recommended inr levels. And here I thought it was only a glitch in what was being recommended for mechanical-valve patients!!!

So the heart institute docs want to see the letter; I asked my pcp's nurses to fax it to them. I was also informed that my doc is dictating a letter about my "noncompliance." I told the nurse that he can dictate away - the levels didn't change, I'm within range, and I'm not reducing my coumadin. (I've decided to get a new pcp) I also told her that I truly believe that compliance consists of staying within range and getting my blood drawn when told. We'll see - can't wait to get that letter.

I'm reminded of "Seinfeld" when Elaine got blackballed as a "difficult" patient.

Valvers of the world, unite!

 

[Guest]

I just checked the National Library of Medicine before I answered and there is no new recommendation that has been published.

Even if there were, the difference between between 3.5 and 3.2 is so small as to make no difference. The serious event rate (roughly defined as a bleed or clot that causes you to have to be admitted to the hospital - not just go to the ER) in my clinic over the past 4 years (13,000+ visits) is between 3 and 4 per 100 patient years. Can this be lowered to 2 per 100 patient years - I doubt it. So what is the sense of getting everyone worked up about a change of a recommendation of 0.3 units? It is just playing with numbers - not making a real difference in anyone's life.

Testing every hour will surely give different values. I can take all 7 testers in my clinic and take a drop of blood from the same fingerstick on the same person and I will get at least 3 (and maybe 5) different readings. So what is the point in worrying about an INR that is 0.1 units outside the range?

The most important thing to remember is that this ain't rocket science. We are not trying to calculate the amount of fuel needed to put an astronaut on Mars and bring him/her back. We are trying to keep people with mechanical heart valves living good lives. It is rare to have an serious bleeding event (see above) with an INR below 5. Try to keep that in mind and it makes your life a lot easier to live.

 

[Georgia]

Thanks for checking

Thanks for checking

Al, I really appreciate your reply and checking for this. You know, the bloodwork and testing and having different values don't come close to the irritation level in having to deal with docs who over-react every time there's a small change. And then to get bent out of shape - ARGH.

Ross, how could you stand it all this time???

I called QAS today to start the process to get a Protime. I think it will suit me.

 

[nadi]

INR level

INR level

Hi

Sorry you are having such a time with you PCP! Sounds like the nurse should be written up to me. I hope you get you home unit soon!

My last 2 tests were 3.5 and 3.73 and the Dr was happy with those numbers left me on 7.5mg and nurse laughed about me wanting green veggies.

I hope you find a good PCP soon.

Take care

 

[Nancy]

Georgia-

"Dictating a letter about non-compliance" sounds like a naughty kid letter that goes in your school folder! LOL. Next they'll get out the rulers and rap your knuckles, or put a gum wad on the tip of your nose and make you stand in front of the class.

You get an F for deportment, Georgia.

 

[azpam]

Very cute Nancy!! I liked that view on Georgia's non-compliance!! She is such a bad girl! To the principal's (i mean doctor's) office!

 

[joy]

Occasionally I am a day off with my testing, but I try to get it done the day that my nurse tells me to. I am going tomorrow. I have been within range, but they wouldn't write a letter of non compliance...are you a kid, or an adult? Sheesh! I like Nancy's view! Reminds me of when I was a kid in high school! Take it easy Georgia, and hey, let's both cross our fingers....I am trying for a pro-time machine too!

 

[Guest]

Worrying about whether or not you are going to have trouble because your INR is 3.4 instead of 3.2 is like arguing over the increased risk of having a wreck if you drive 34 MPH instead of 32 MPH.

 

[Georgia]

HALLELUJAH

HALLELUJAH

Went to new pcp yesterday. My records had been transferred & everything.

This guy says: "WHY did Dr. *** want to reduce your coumadin? You were right in range!" And he told me that he'd never reduce doseage on one mildly high reading - always get a second in a week. I think I may have died and gone to heaven. And he recommends a range or 3.0 to 4.0 for mechanical valve patients. And will prescribe a Pro-time unit.

And I had a reading of 3.7 yesterday and the nurse said just one more in range and we go to monthly checks.

Ross, there is hope. And thanks to all of you and particularly Al, I KNOW what I should look for in a doc who's monitoring coumadin.

 

[nadi]

Good News

Good News

Georgia,

That is great that you found a Dr that has common sense! he he
enjoy your 4th

 

[fyrfytr]

Hey Georgia,
I am with Nadine, Glad you found a New and Good Dr.! I just got my INR at 3.5 and they were all thrilled. Now they get to stick me only once a month. Take Care
Dave

Keep your fires small!
________________________________________
Surgery: 4/21/03
Aortic Aneurysm Repair
AVR, with a St. Jude Mechanical
Heart Center of the Rockies