new to coumadin

[Jessie316]

Hello everyone,
I am new to coumadin my AVR was on 7/6/09. Basically I have been unable to be regulated since surgery. I was therapeutic when I left the hospital next day when tested I was 4.0. My surgeons range for me was 2.0-2.5 which I think is small. I have only hit 2.0 once since home. And last week I was 1.4 and my surgeons office demanded that I be admitted because I was not therapeutic. This is where I discovered how vastly different and hours of travel distance apart of hospitals can have vastly different protocals. I was yelled at, my PCP and coumadin clinic was yelled at for not having admitted me for an INR of 1.4. My PCP did not understand why she had to admit me and when the hospitalist came into my room to admit me he quote unquote" I am here to admit you but I truly don't understand why I have to admit just that Boston said I had to". I was discharged on WEd and tested again on Thurs 4.2. In my eyes they did not regulate me as in their eyes they did. I know it's not an exact science but...... So now I am truly confused. My goal is to home test and going through the process for insurance approval for a coagu check( I like it because it's small and compact). How long can it taske to regulate you. According to my surgeons office if you are out of your range in either direction you are to be admitted to the hospital. My concoern is I will be returning to work next month and it is unfeasible to be admitted every week fora day or so to return to therapueutic level.

 

[Karlynn]

I'm about 95% positive that your issue with not getting regulated is due to the doctors and not the drug. You are correct 2.0 - 2.5 is really too small a range. The range for Aortic valves is usually 2 - 3. I'm guessing that your doctor has you on that tight of a range for the old adage that "doctors fear bleeding, patients fear stroke". Since you were "fresh" off surgery, I guess I'm not surprised they readmitted you for the low INR. Most times people are prescribed Lovenox shots to give themselves at home twice a day until they are in range. (Note that heparin or Lovenox do not reflect in the INR, so once your INR is in range - that means it's the Coumadin dose that got you there.)

It would really help if you could give us your dosing history. What were you taking when you got the 1.4, and then the 4.2 etc. You should be keeping tract of this yourself too, so that you can see trends.

Now, your doctor not understanding why you were being admitted is one thing, if he didn't understand why AND wasn't going to put you on Lovenox (which is a low molecular weight heparin) then he doesn't really understand how to manage you.

Make sure you read and view all the stickies found at the top of this forum.

 

[jax]

i am two months out of surgery and this last monday was the first time that i was in range since surgery. it takes time and although my inr crashed a couple of times down to 1.26 and 1.3 i was never admitted into the hospital. when my inr dropped the second time down to 1.26 i was put on the lovenox shots and gave them to myself at home. your doctor could have easily done this and you wouldn't have had to be admitted into the hospital. sure it wasn't fun to give myself the needles but i would rather do that then to be stuck in the hospital. Your range is definitely too small and with it being so small you may have a harder time staying in range. when i had to bridge with lovenox my cardiologist wanted me to bridge until i hit 2.0 which only took me four days after my pcp doubled my dose. you should really consider talking to your doc and mentioning lovenox just in case you do crash again. atleast you will be able to stay in the comfort of your own home.

 

[catwoman]

Jessie:

You're only 4 weeks post-op. As you begin to feel better and become more active, your INR **will** drop because your metabolism is increasing. Warfarin (Coumadin) is metabolized in the liver, and as you become more active, your blood is making increasingly more trips in the liver, where the drug is being metabolized. Thus, more warfarin is required.
All things equal (other meds, age, sensitivity to warfarin, overall health), someone who bikes, swims, walks, jogs, etc., on a frequent basis will require a higher dosage of warfarin than a couch potato.
This could explain why your INR has dropped. (Use a 7-day weekly pill box so you'll know if you've forgotten a dose, which will also cause your INR to drop.)

Your range is too narrow. Should be 2.0-3.0. I have a Hemosense INRatio, and love it. It's small, very comparable to the CoaguChek. My INR does not stay absolutely perfectly in the 2.5-3.5 range. My cardiologist prefers it at the higher end (3.0-3.5). I'd prefer it to be up to 4.0.

Most of us keep Coumadin diaries of some sort. We note our daily dosage and INR results + anything unusual (being ill, going on/off meds that can affect the INR). Tracking your dosages and results often helps you when you need to change dosages ("Gee, when my INR was X.X, I dropped/increased it to Y.Y and that got me back on track").

I agree with others: Using the hospital's revolving doors may not be the only answer to your situation. Your doctor should be Rxing Lovenox shots until you're back in range.

 

[ALCapshaw2]

First, it appears that NONE of the Doctors you have seen have a good understanding of how to manage Coumadin.

First, ONE in-range test is NOT a sufficient condition for showing that your INR is STABLE. It only shows that you were at an In-Range point at the time of that test. Without have at least 2 tests in a row (preferable at least a week apart), there is NO WAY to know if your INR was Rising or Falling or Stable at the time of that ONE test.

Second, it is Very Rare to admit a patient for a slightly High or Low INR. As others have said, the usual protocol for LOW INR is to administer Lovenox Injections to protect you until your INR is shown to be In-Range and Stable. As others have said, the usual recommendation for AVR patients with NO additional risk factors for stroke is 2.0 to 3.0

Can you find a Real Coumadin Clinic in your Area? Dedicated Coumadin Clinics *usually* are much better at understanding and regulating anticoagulated patients than single providers, especially if those single providers are 'out of date' on the latest protocols.

Have you read AL Lodwick's website www.warfarinfo.com?
That is an EXCELLENT source of accurate information on managing Coumadin / Warfarin.

'AL Capshaw'

 

[Ross]

Jessie please tell us what your doses are now, when you were last tested, the kind of diet you eat and any other prescriptions you take. We can get you straightened out. We've had many a happy customer.

2.0 to 2.5 just shows that person does not understand Coumadin and thinks it's a constant, which it is not. It can very greatly from one moment to the next. If your between 2.0 and 4.0, you should be happy and SO SHOULD THEY. Your surgeons scare me with there admit for everything attitude. Think it's time to shop for a new Doctor or Coumadin Clinic.

 

[dick0236]

First, it appears that NONE of the Doctors you have seen have a good understanding of how to manage Coumadin.



Have you read AL Lodwick's website www.warfarinfo.com?
That is an EXCELLENT source of accurate information on managing Coumadin / Warfarin.

'AL Capshaw'

I agree with Al and the others. Warfarin management is not, normally, that difficult. Find a doctor or clinic that has knowledge of the drug. Your problems probably have more to do with your "managers" and not with the drug "Coumadin or Warfarin". Sometimes, it takes a little while to find your "correct dose".....and even then, your dosage will change every now and then......that's why we test reasonably frequently.

 

[Jessie316]

I am connected to a coumadin clinic with my PCP. My PCP would have been happy to play the lovenox thing. however it was my surgeons office that demanded I be admitted. ( Who I have not seen I see him this thursday). My PCP , coumadin clinic an dcardio all have the protocal of lovenox, however they were trying increased dosageds of coumadin prior to starting lovenox was the original plan until my surgeons offcie got involved. Here are some of coumadin dosages:Since hospital I have been on 8/7 I was INR 4.2 coumadin clinic gave me fri2, sat 2 and 8/9 Sun 4 mg. On 8/10 INR 2.8 and dosage 8/10 6 mg, 8/11 4 mg and retest wed. So we will see. Thanks for the help guys.

 

[Ross]

They are doing it wrong. They need to put you on 5mg and leave you alone for 4 to 7 days and then test. What they are doing now is equivalent to monkeys throwing darts at the board and hoping they score. They will not find the proper dose doing that.

P.S. Your surgeon is no longer the shots caller, your PCP is. Tell him to grow a pair.

What are you eating? Please don't tell me they told you not to eat deep green veggies or other high Vitamin K items.

Also, what about other medications?

Seriously, we may not be certified doctors, but we are self dosers and home testers and we DO understand quite a bit about how this drug works. We will get you stable if they can't.
We had/have the best teacher in the world, in my opinion, Al Lodwick. He swears he learned from us.

Just give us all the information you can and we'll go from there. Please realize, I will not tell anyone to go against their doctors advice unless they have proven they don't know what they're doing and believe it or not, around 70 to 80% of them don't.

If you'd like to educate yourself even more (I guarantee you'll know more then your doctor!) Check out these two sites:
www.warfarinfo.com
http://www.warfarinfo.com/warfarinfo.com2.htm
http://www.aafp.org/afp/990201ap/635.html