Ol' bugaboo on Coumadin vs. warfarin

[catwoman]

Last weekend, an acquaintance told me at dinner that her husband has to get lab draws (not fingersticks) EVERY WEEK -- because doctors aren't able to stabilize his INR. He's been on warfarin (generic) for several years due to DVTs.

I was about to ask several questions when another friend, who works in the cardio dept of a med school, asked if he was on generic or trademark Coumadin. When she heard he's on generic, she said the yo-yoing is no doubt due to his being on warfarin rather than Coumadin. After all, doctors at that med school pooh-pooh generic, saying you can't possibly get stabilized on it because of the (as she said) 20% variance in the generic.

Something happened that changed the topic of conversation.

I could think of a whole lot of reasons why his INRs fluctuate and I plan to call or e-mail her so they can explore the cause.

My guesses:

1. too narrow of an INR range
2. starting & stopping of other meds
3. patient is forgetting a dose within a couple of days of INR test and missed dose isn't being reported when he reports for his lab draw
4. crappy ACT manager
5. crappy handling of blood sample being sent to lab
6. generic warfarin isn't working (I really doubt this one, though)

Any other thoughts that I can throw at my friends?

 

[ALCapshaw2]

Get a Home Tester?

 

[Cris N]

Arrrggghhh... don't ya love it when these 'professionals' seem to know everything.

I would probably change the order of your list and put #4 first. Only one other thought - and you may have seen me write about this before. I am very sensitive to dietary changes. I can't/won't maintain a consistent diet of greenery and I found that even the addition of one extra iceberg lettuce salad in a week could have a fairly significant effect on my INR. With the help of my ACT manager at the time I slowly started increasing my Vit K level - first with V-8 juice, then with full RDA in my multivitamin, and now I take a regular multivitamin with 25 mcg Vit K and a 100 mcg tablet of Vit K. Now my dietary inconsistency has virtual no effect.

There have been some studies that support this concept - great for people who aren't consistent.

What I meant to add was, since I've been doing this my INR has been, for the most part, very stable.

 

[sue943]

I cannot believe that the use of generic warfarin has anything to do with it at all. I have only had generic and not always the same brand, our system is that we are given whatever the pharmacist has in stock at the time. My INR is really stable and always has been.

 

[ChouDoufu]

you can add #7. poor quality of instruction at that medical school

either the administration there are voodoo witch doctors, or they've
been bought out by the lovely donations from the pharma companies.
name brand drug company pays for some major equipment or an
expansion, cause they're so civic minded of course, and suddenly
the students are getting indoctrinated to only prescribe genuine
trademarked drugs. coincidentally those of the major donor.

generics bought in the usa are the same as the name brand. the drugs,
the transport pipeline, the production facilities have all been inspected
prior to fda approval.

generics bought online and imported privately may be different. if
from canada or england or india, they should be fine as long as bought
from reputable pharmacy. from other countries, you never know.
after a couple weeks taking warfarin bought at the hospital pharmacy
in china, my inr test showed me to be essentially un-anti-coagulated.

 

[Freddie]

One more possible thought Marsha:
Maybe he's double dosing when he forgets?

 

[catwoman]

Thanks for everyone's comments.
Will call wife of my friend who's on warfarin and relate to her the comments here.
I did tell her that Medicare covers home testers for a-fib & mech valves. However, I doubt that they're covered for DVTs. Her husband is on Medicare but hasn't retired yet.

I can try -- but won't hold my breath -- to educate my other friend who works at the med school and try to convince her that there are a multitude of reasons why someone can't get in range. And it's very seldom due to being on generic vs. brand name.

 

[olefin]

I feel that consistent diet should be added to your list.

My INR has always bounced around a little but I feel it's because of the way I eat. But I'll never change that.
After home testing/dosing I been spending more time the control range for I test more frequent.

As far as Coumadin and warfarin... I'd taken Coumadin for 17 years, switched to warfarin and saw no difference in results. I get my warfarin at Kroger's.

 

[Eva]

I would add, Marsha, the this person checks certain vitamins also. There is a cologne cleanser and Calcium that contain vitamin K. Also, in my personal situation, everytime I drink 'red bull', my INR drops down.

 

[catwoman]

I would add, Marsha, the this person checks certain vitamins also. There is a cologne cleanser and Calcium that contain vitamin K. Also, in my personal situation, everytime I drink 'red bull', my INR drops down.

What is a cologne cleanser???

I'd be really surprised if my friend drinks Red Bull.

 

[Eva]

Marsha, I had a typo...I meant colon cleanser. See photo attached.

When I tried it, I did not read the lable before ... It dropped my INR a LOT!! it took me a while to analyze what I did differently that week!!

 

[AgilityDog]

I know that water retention affects my INR, as does getting dehydrated - usually retriever training in the sun, and forgetting to drink.
Activity level is also a biggie.

 

[mtnmel]

Warfarin's stated tolerances

Warfarin's stated tolerances

The issue here is that generic warfarin does not conform to a stated 20 percent plus or minus tolerance of pill dosing. The FDA is not checking each generic mfr's dosing quality. So, who is? It could be plus or minus 40 percent. These are cheap generic drugs.
My PT INR was all over the place for months after my valve replacement. It settled right down when I switched to Coumadin, a brand name with higher quality control and accurate dosing.
It is a mistake to lump warfarin and coumadin into the medicine-wide argument about docs and their prejudice for brand vs. generic medications. That clouds the real issue of dosing accuracy.

 

[Cris N]

The issue here is that generic warfarin does not conform to a stated 20 percent plus or minus tolerance of pill dosing. The FDA is not checking each generic mfr's dosing quality. So, who is? It could be plus or minus 40 percent. These are cheap generic drugs.
My PT INR was all over the place for months after my valve replacement. It settled right down when I switched to Coumadin, a brand name with higher quality control and accurate dosing.
It is a mistake to lump warfarin and coumadin into the medicine-wide argument about docs and their prejudice for brand vs. generic medications. That clouds the real issue of dosing accuracy.

This discussion has taken place many time on this site. One thing I've found is that there are some folks who swear by the brand name Coumadin - that's it's the only way to maintain a stable INR - maybe that's true for a few. Most of us, however, have found that the generics (specifically those manufactured by Barr, Jantoven, & Taro) work just as well.

I would hope that people new to a warfarin regimen not be frightened into thinking that they can only get good results from Coumadin and would at least try the generics if they are concerned about prescription cost.