Nick's INR is out of whack!

[akaShei]

At the last check, Nick's INR was 5.8 & the nurse said "Oh, my gosh!" The therapeutic range for him is 2.5 to 3.5. He was feeling sick, lightheaded & dizzy. It doesn't seem like the nurse adjusted it enough to make a difference. She just told him to stop for one night & take 2.5 mg less just once for the entire week. He was taking 5mg on Mon, Wed & Friday & 2.5 the other days. Now he's taking 2.5 on Wed, too. Doesn't seem like much difference to me. We'll see what happens at his next check. He is very frustrated to say the least & this is why he didn't want to take Coumadin in the 1st place. His grandfather & uncle had/have difficulty keeping their levels steady.

 

[Karlynn]

Sorry to hear he's having issues. The INR can be hard to adjust after surgery but he will get in range and be stable - if he has a Coumadin manager that knows what they are doing.

It's possible, but I'm not convinced that his feeling of unwell has to do with the 5.8 INR. It's high, but not extremely high. I've been higher than that several times in 15 years and never knew it except for the test. Was he bleeding any place, such as his gums or nose? This is how people typically can tell they may be too high. A few members report that they can "feel" if they are too high. I've never been able to gage my INR by how I feel.

Lets see if we can ferret this out with a few questions. What was his last INR test before the 5.8 and how long ago? How was he tested, finger stick machine or lab draw? What have his weekly dosages been.

When adjusting Coumadin it should be done by looking at his weekly dosage total and adjusting by a certain percentage, then dividing that number up by 7 for his daily dose. So start thinking in terms of weekly doses. It makes it much easier to understand adjustments.

So before his 5.8 INR his weekly dose was 25. So without considering the held dose, the nurse gave him an instruction for a 10% decrease by having his go with 5 days of 2.5 instead of 4. If his held dose was 5, that would mean the nurse gave him a 30% decrease for one week and a 10% overall decrease going forward. That seems reasonable. He's too new to Coumadin to know if it will cause him to go too low.

When is he testing again? I'm hoping you are saying it's in a week. You want to make sure that the INR wasn't a fluke and that the doage change isn't making him go too low. And you also want to make sure that if it wasn't a fluke, that the dosage change was enough or too much.

Again, I would hesitate assigning his being sick, lightheaded and dizzy to the 5.8. If it was making him feel those things then they should be concerned that he was bleeding somewhere. If he is still feeling that way he should see the doctor. An INR of 5.8 most likely wouldn't cause someone to bleed spontaneously internally where there is no existing problem.

 

[geebee]

I agree with Karlynn that Nick's symptoms are most likely not being caused by a high INR. I have had many INRs above 5.0 due to other meds, illnesses, etc. and have never had symptoms other than easier bruising or gum bleeding.

 

[ALCapshaw2]

I *ASSUME' the nurse did NOT do a retest to see if that reading is a fluke. FWIW, my Coumadin Clinic uses i-STAT Finger Test instruments. They have a standing rule: ANY time there is a reading over 5.0, they REQUIRE a retest by veinous draw and Lab Test, just to be sure.

I've had TWO apparently FALSE readings over 5.0 this year that both came back 3.2 from the Lab Test. It is always wise to Double Check any HIGH or LOW Reading!

'AL Capshaw'

 

[Ross]

I agree with my fellow Vr's, INR is not what is causing him to feel the way he does, something else is going on there. Provide as much information as possible and we'll see if we can't pin the INR problem. Doesn't seem to be the manager in this particular case, though a second check test would have been nice.

 

[akaShei]

Maybe we jumped to conclusions?

Maybe we jumped to conclusions?

The day of & day before he got checked, he was feeling bad. We assumed it was because of the INR, but it's quite possible that it was caused either by more activity or the stress/grief from the death of our friends' 8 yr old daughter on March 9.

I was thinking 5.8 was really high. One week before, he had his blood drawn at the family dr's office & we were told the next day that the INR was 3.3. She instructed Nick to continue alternating the 2.5 & 5 as instructed by the hospital at discharge. Then this past week, we went to the to the coumadin clinic at the cardio's office to avoid a waiting room full of sick patients. They used a finger stick machine & we received the INR of 5.8 on the spot. I will certainly request a recheck if it's above 5 again - didn't think that it could be a fluke. She mentioned that being on Amiodarone is causing the blood to become thinner as well. Also, the held dose was 2.5 & he will be checked again next week.

Thanks for the advice. I know we need to be patient and that it takes time to get it steady.

 

[Karlynn]

I haven't read yet about your friend's daughter, but regardless of circumstance it's heartbreaking to lose a child. So I'm sure this has given him some stress that would affect his body.

It appears the instructions you were given were correct. Amiodarone does affect the INR and raise it. Other's that have used it can shed more light on how long it takes to do this.

With the held dose, his INR should already be on it's way back down, so try not to stress out over bleeding. Report anything suspicious to the doctor, but try not to be too concerned. Most of us would rather have a 5.8 than a 1.5. It's always easier to lower a high INR than to raise a low INR.

You'll both get the hang of this. So much of the education related to Coumadin scares the heck out of people, and it really isn't a scary drug to live on a daily basis.

Since it hasn't been a month since his surgery, you may be right that his feeling of unwellness was a result of pushing it a bit too much. Our bodies have not-so-subtle ways of telling us to slow down.

 

[Guest]

The nurse does not exactly inspire confidence in her ability to manage warfarin by saying, "Oh my gosh" to an INR of 5.8. I see one of these every day. Hardly ever does anything happen.

Warfarin slows the ability of the blood to form clots.. If he can feel his blood not clotting that is pretty amazing. It does not thin the blood, so there is nothing to feel.

 

[geebee]

The nurse does not exactly inspire confidence in her ability to manage warfarin by saying, "Oh my gosh" to an INR of 5.8. I see one of these every day. Hardly ever does anything happen.

Warfarin slows the ability of the blood to form clots.. If he can feel his blood not clotting that is pretty amazing. It does not thin the blood, so there is nothing to feel.

Al,

That's nothing. When I was in the hospital in November, the nurse that was doing my meds was wondering why my coumadin wasn't being held when my INR was 3.1. The chart didn't even indicate that my INR range was 3.0 - 4.0. I told her and she said that range was too high. I asked her why and she said that's what they were taught. I told her she was not being given all the facts and should do some more research.

Just another example of staying completely aware while a patient. If you are not fully aware, you need a family member with you at all times or you put your life in danger.

 

[Karlynn]

Yes, it was the "oh my gosh" that made me do the calculations to see if she was correct with her instructions. And I was a bit surprised that she was. Usually an "Oh my gosh" manager will say hold 3 days and throw salt over your shoulder - or something like that.

 

[RCB]

We got trouble here!

We got trouble here!

Yes, it was the "oh my gosh" that made me do the calculations to see if she was correct with her instructions. And I was a bit surprised that she was. Usually an "Oh my gosh" manager will say hold 3 days and throw salt over your shoulder - or something like that.

This is ridiculous- why didn?t she just dial 911!

That kind of comment is so unprofessional and not helpful to the pt.!

 

[akaShei]

The "oh, my gosh" may have been because she was surprised to see it jump from 3.3 to 5.8 in one week. To give her credit, she did seem to know what she was doing. When I asked how dropping one night & lowering one day would get him back down to where he needs to be, she did not waver. She just said we'd check it in one week. I also asked how high is too high & she said she'd seen much higher. She did not say anything about it possibly being a fluke as mentioned here, so I am concerned. She's the coumadin clinic nurse for a large cardiology practice, so I am assuming she knows her stuff, but I do plan on staying on top of things.

Just curious, regarding Coumadin, if it isn't thinning the blood, why is it so frequently called a blood thinner? The nurse even referred to his level as being too thin.

 

[Guest]

We have a new doctor at he hospital. He had a patient this week who had an INR of 3.1. He was going to cut her warfarin dose from 4 mg to 3 mg. I told him that if he did that I could almost guarantee that the nurse who was imto give the warfarin would call him about 7 PM to make sure that he knew the patient was toxic and did he want to give it anyhow. He decided to follow my advice. But the the INR went too low.

 

[Karlynn]

I'm glad to see that you have some faith in the nurse's knowledge. I think we are very sensitive to Coumadin mismanagement here because we see a lot of it and we see a lot of people who are supposed to know what they're managing, but don't. So keep on educating yourselves and you'll be able to catch errors when you need to.

 

[Ross]

Just curious, regarding Coumadin, if it isn't thinning the blood, why is it so frequently called a blood thinner? The nurse even referred to his level as being too thin.

Because Coumadin is not a blood thinner. It is an anticoagulant. Coumadin does not change the viscosity of the blood, it inhibits its ability to clot.

The Amiodarone is going to play with the INR some and probably is going to be the largest single factor in getting it stable, but it will come.

 

[akaShei]

Nick's back in range. Thanks for help!

Nick's back in range. Thanks for help!

At the last check, Nick's INR was 2.5. My faith in the clinic nurse's knowledge & instructions has been restored! I should have asked why she made the comment "oh my gosh", but I didn't have the nerve. The difference in one week from 5.8 to 2.5 was even greater than the 3.3 to 5.8 the week before, so that blew my theory of it being because of the drastic change. What matters now, though, is that he's in range & feeling happy.

I looked at the machine they use. It is a Coagucheck. Is that a good one?

 

[Guest]

I have done about 20,000 tests on CoaguCheks

 

[Persianlady05]

To Aka

To Aka

Sorry to hear of your problems with INR 5.isnt too high we can feel sick and achey .I have had a very hard time with mine last yr it went up to 10 had hemotomas all over the place i notice when mine get too high my top of my feet begin to hurt when i flex them and it hurts to walk on them one time the back of my shoulder began to hurt i know i had not strained it or done anything out of the ordinary later I found a hemotoa on it its at a normal range now this is not a easy life for us i tried to get a home montior but medi-cal in ca wont pay for it which i understand take care chris