New to Coumadin, trying to understand instructions given

[almost_hectic]

Still working on stabilizing my dose since surgery which it seems to be settling in rather easily after only a couple of adjustments since Ive been home. I am however a bit puzzled why instead of setting a normal daily dose, I have been instructed to alternate between half and full doses every other day. Well actually that was the original instruction but then it was decided that was to confusing so they locked it down to a M,W,F dose and a S,T,T,S dose. Which as it is seems low to me but my last reading on this method was 2.7 My dosage is as follows:

Sunday - 4mg
Monday - 2mg
Tuesday - 4mg
Wednesday - 2mg
Thursday - 4mg
Friday - 2mg
Saturday - 4mg

So what I dont get is, yes theres an odd number of days in the week so it gets confusing to alternate every other day. BUT, if Im alternating between 2mg and 4mg every other day... why not just have me take 3mg every day? I cant imagine it being any simpler than that! But I was told they like to alternate. Why would alternating be more advantageous than consistency? Its really no big deal, I can follow the instructions without any problem, I just find it odd.

 

[pellicle]

I agree, 3mg daily makes more sense and being irregular only succeeds in increasing chances of mistakes increasing chances of a reading appearing slightly higher or lower. I have no faith in dosing clinics. They are full of people with just enough knowledge to think they know more than they really do. Not many are critical thinkers.

To my mind I see you have two options to pick.
1 disobey: take 3mg daily and see where that goes
2 follow their instructions and see where that goes

All things considered I don't see either being significantly different to the other.

As an observation that's a very light dose. Have you been tested for the genes?

http://emedicine.medscape.com/article/1733331-overview

 

[dick0236]

I fully agree with pellicle. Alternating doses does not make a lot of sense. I am a big believer in using a seven day pillbox and loading a pillbox will be different every week with their schedule.....leading to error?? Their schedule might make it a little easier for them to make dosing adjustments.....but your low dose should be very easy to manage anyway.

 

[scott.eitman]

I agree with Dick and Pelicle, with one exception. I would discuss this with the coumadin clinic before changing the dosage. At this point, I figure Almost Hectic has a bottle full of 4 mg pills.

I take 4 mg daily, but on Wed I take 2 mg. I have always thought this to be flawed, but keep doing it...and I stay in a therapeutic range.

 

[pellicle]

Hi

Scott is correct, discussing this question with em is "the right thing to do" , my cynicism of their being amenable to discussion; not treating you like an idiot is shining through in that I did not suggest it.

Can I ask you almost_hectic what brand you are on? What ever brand it is be aware that mix and matching brands won't work well and may lead to erattic results in INR.

If you can have a mix of pills which allows fine tuning then that's ideal. I have 5, 3 and 1mg tabs on hand all the time.

 

[almost_hectic]

Well I was checked today. Not going to a clinic right now but the cardiologists office. I was 1.7. So they suggested upping my Wednesday dose from 2 to 4. And see where I am this time next week. I commented I'm running low on pills (4mg which I was cutting in half) so they wrote a new rx for 2mg pills. I think part of the thing is they are still finding out where I normalize at a stable dose (of Jantoven which I was already on)

So that means this week is 4,2,4,4,4,2,4 for 24mg

Oh I forgot to mention, one two weeks ago I was at 2.7, so not sure why the drop, no real diet changes. But I did begin cardiac rehab so I've been getting a lot more exercise... Would that cause a metabolism change or anything?

 

[almost_hectic]

Tested again yesterday, even after dose increase my INR only went from 1.7 to 1.8 so now the weeks dosage is 4mg every day and test again in one week? I'm still in range for the onx valve but below where they want me to be right now. Does anyone know why they want your INR slightly elevated for the first three months after a new mechanical valve?

 

[dick0236]

Does anyone know why they want your INR slightly elevated for the first three months after a new mechanical valve?

My guess is that shortly after the trauma of the surgery they want to minimize any potential blood clotting.

 

[W. Carter]

Here is a dosing chart. It is exactly what i'm on. I am on 42.5 mg weekly, 7.5 mg 3x weekly, 5 mg 4x weekly. My inr is usually spot on between 3 and 3.5 all the time. Alternating days is the way the V.A. pro time clinic does it. The only difference in the chart and my regiment is I am prescribed 2.5 mg tablets, I either take 2 or 3 tablets depending on what day it is, no cutting pills in half. One important thing to remember, if you smoke cigarettes or use any kind of tobacco you will need more coumadin to get your inr level up. I quit smoking 8 mo. ago and had to adjust my dosing down.

Link to dosing chart.
https://intermountainhealthcare.org/...ncid=520185654

They give you a card to follow, as you can see i've been on the same dose since 7/16 of this year. Disregard the 17, don't know why it's like that. It's actually pretty easy to get used to.

 

[Boomanchu]

I've been home testing since March but have had to play the game of "obeying orders" I finally got a prescription for a second strength but not what I needed to make my dose work. Last week I sent the lab my doses and INR and to keep in range I had to do .75 of one strength and .75 of the other and I kept in range. The nurse chewed me out for changing my dose and said she didn't understand how I came up with the figure for my daily dose. I was so irritated that my answer was. "I used math, you should try it" I was told that "all that matters is the weekly average". I happen to think that it's my life and reporting once a month like I'm being ordered to puts me at risk but trying to explain that gets me nowhere. My father always told me.... liars always figure but figures never lie.

 

[pellicle]

Hi

... I was so irritated that my answer was. "I used math, you should try it"

best laugh I've had here yet I reckon

10 out of 10

 

[pellicle]

Hi there

Well I was checked today. Not going to a clinic right now but the cardiologists office. I was 1.7. ...

So that means this week is 4,2,4,4,4,2,4 for 24mg

myself, I think you need to be going to at least 5 daily ... if you want to be over 2 that is ... clearly 4 daily is not doing it. I applaud them easing you into it, but its well past time to get you into the pool.

Oh I forgot to mention, one two weeks ago I was at 2.7, so not sure why the drop, no real diet changes. But I did begin cardiac rehab so I've been getting a lot more exercise... Would that cause a metabolism change or anything?

yeah, stuff like that happens. I've just had few weeks where my INR shot up to 3.8 (and I reduced my dose) and I've been monitoring myself twice a week and charting it. Its gradually returned (and I've been gradually increasing my dose in small steps) to my more usual needs ... so as to why everything changed is unclear. Its obviously not something I ate because it persisted for 3 weeks. What is important is that we monitor and adjust. This is why I keep harping on test frequently, monthly is not sufficient.

 

[pellicle]

I thought I'd use your data here as an example of why I'm against these sorts of doses

So that means this week is 4,2,4,4,4,2,4 for 24mg

firstly this whole "weekly average" thing is a simplification (or stupidification) of the idea that it doesn't matter. If this was true why not take 24mg on Monday and just wait again till next Monday ... Of course the proponents will say "well that's obviously too much" ... so when is it not "too much"

4 is double the dose of 2 ...

Now to get to the point, its well known (in pharmacology) that warfarin is reduced in your body at the rate of about half every 2 days (there is of course variation on that, both between different people and even within a person over time).

So if we were to apply this formula to your dose it will (after stabilisation) leave you with a theoretical level variance of this:

the flat line is simply taking 3.43mg daily

Of course there will be differences between reality and this simple model, but the point is that those variations will result in either higher or lower residual warfarin levels depending.

So you can see that sometimes your residual is over 10 and other times its under 9 ... I can't see that having zero effect on your INR