Please help...especially Al if you are out there

[T-Money]

Hi Folks.
I've kept a real positive attitude about this, but after 5 weeks post-op, my INR level is still less than 2 (today it was 1.6). In the 5 weeks I only made above 2 once (2.8) and then it was 1.6 the next week. I had AVR plus an aneurism repair and should have an INR of 3-3.5. This is not due to a lack of dose increase by the cardio office that monitors me each week. I went from 5mg per day to 10mg per day in this time period. I am taking the generic warfarin tablets and was told that I may be resistant to the generic. That doesn't make a whole lot of sense to me, but that's what I was told. I was given some sample of the real deal Coumadin today and told to take 10mg tonight and tomorrow night and to go in on Friday for a check. I am also going to have to get lovenox shots (2 per day) until the INR is up. This is all very frightneing and worrisome to me. Any input from the Coumadin pros out there would be so so so much appreciated. I've been very careful with the vitamin k foods and really avoided them hoping it might make a difference. Any advice, info., or stories would be great. Please send them along if you have them.

 

[ALCapshaw2]

Hello Money,

AL#2 here.

Lovenox shots until your INR is in range is a GOOD idea.

Testing only 2 days after making a change is a BAD idea since it usually takes 3 or preferably 4 days for a change to fully reveal itself. IF you then make a change before the first change has taken full effect, you will likely be chasing your tail.

Let's see what AL#1 has to say.

'AL Capshaw'

 

[Guest]

My guess is that you have made a good recovery and are fairly active by now. More activity increases increases your heart rate. A higher heart rate means that your blood makes more passes through the liver. More passes through the liver means that your warfarin is more rapidly metabolized. This means that your INR will go down even with an increasing warfarin dose.

Saying that you are resistant to generic warfarin makes about as much sense as saying that you are resistant to to being injured by a Ford, so we'll try hitting you with a Dodge. I have over 350 pages on my website about things that throw off warfarin, but the doctors always settle on generic vs brand. That way they do not have to think too much about it - I guess.

You don't mention if the doctors ever cut your warfarin dose based on testing more frequently than once a week. If they have, then this is probably a big part of your problem. The best way to dose warfarin is to look at the dose over the previous 7 days and base decisions on that. Wg=hen the decision is based on shorter intervals, ther e is not much more chance of being right that pulling a number out of a hat.

Giving as much detail as you can about dose, dose changes, INRs and dates can help decide what is happening.

 

[T-Money]

Thanks for Replying

Thanks for Replying

Hi Guys.
Thanks for sending me your suggestions. I may have been a bit unclear about some of the facts. The clinic I go to has never cut my dosage, only increased it. My testing was also done on a weekly basis until this week (they normally check me on Friday's). So, the adjustments they made and the testing schedule sounds like it is OK according to what you two are saying. The one thing that I did notice after reading your comments was that the one time it was close to therapeutic range, I was on 50mg of metoprolol per day rather than 25mg. Al Lodwick, based on what you are saying a faster heart rate could influence the effect of Coumadin on me. My heart rate has been fast before and after my surgery. It is over 100bpm during the whole day, exercising or not. I will inquire about this today. I also have been exercising more and more since getting out of the hospital. I did mention exercise yesterday and the nurse that manages the Coumadin dosage for me told me that she didn't think that was it. Any other comments would be appreciated.
THANKS!!!!!

 

[ALCapshaw2]

Several of our members have reported that it took a while to get their INR in the desired range following surgery. You are going through a LOT of changes at this time, many of which may affect INR, including healing of your body, activity and exercise levels (in spite of what that one nurse told you), and medication changes.

The Lovenox will protect you until your INR stabilizes in the target range. It sounds like your Coumadin Clinic is taking a reasonable and careful approach. It just takes time, patience, and FAITH. It CAN be unnerving. That's where VR.com comes to the rescue. Let us know how you are doing.

Keep the Faith!

'AL Capshaw'

 

[Guest]

Exercise is a HUGE factor. I have seen several people who worked their INRs all the way down to 1.0. That does not mean that exercise is bad, you need it to get healthy.

I had a letter to the editor published about this in the American Journal of Cardiology. It was several years ago and nobody has ever disputed it.

I also suspect that at 100 BPM your heart is functioning rather efficiently. When the rates get up above 120 or so the efficiency seems to go down. When blood carrying warfarin hits the liver, the enzymes metabolize a minute amount but they do so almost instantly. Slow heart rates with the blood passing slowly through the liver does not provide efficient metabolism. Remember that the dose of warfarin is not important. It is the INR that it produces that matters. From a survey that was posted some months back, it appears that most valvers take fairly high doses.

It is a pain to have to get Lovenox shots but don't worry about your warfarin. Put all of your worry effort into getting to the point where you are so much better than you were before your surgery that you can't believe that you were once in such a bad situation.

It does not sound like you are getting poor warfarin management.

 

[T-Money]

Bless You

Bless You

Thanks Al.
I know you are a real pro, so hearing those words from you is encouraging. Thanks you for such a quick response. I'm currently trying to psyche myself into self administering those lovinox shots. You're the best!!!!!!!!!!!!

 

[Guest]

Thanks but no sympathy from here. They are just like Insulin shots and I do that twice a day.

Just pinch an inch and poke it in. If it stings too muh take it back and move an inch or two. Try to not blow the little bubble out of the syringe or you will get mucho bruiso. Many call it eggplant belly.

 

[Blanche]

T-Money:
Some people would rather give themselves the shots. I'm not one of those people. But, I am told that it does make it easier for some.
Blanche

 

[T-Money]

One More Question Please....

One More Question Please....

Sorry to keep bothering you guys, but this mess I'm dealing with is worrying me to death. When I picked up my Lovinox shots earlier today, the pharmacist said that he had patients who were resistant to coumadin (generic or name brand) and were on full time Lovinox. Because I am in a jumping to conclusions state of mind, I am afraid I may be one of these people. If I did manage to get my INR to 2.8 once using generic warfarin and also had my INR level vary from 1.5-1.9 on other occasions, would this be compelling evidence that I am not Coumadin resistant. I didn't know if it was a matter of degree or if you were resistant it just wouldn't move your INR period. My cardio office was being real circumspect about this today which only scares me even more. Any thoughts on the rare condition of Coumadin resistance would be helpful. Self-administed shot #1 occurrs in 1 hour. I know I won't get any sympathy from Al, but I am actually feeling kind of proud that I could give myself a shot. For me, it's a matter of conquering one of my top 5 fears (right below snakes). Thanks in advance for any help you may offer.

 

[ALCapshaw2]

I hear you 'Money'.

This knowledge of what CAN or MAY go wrong is one of the reasons a lot of Doctors don't like their patients to 'know too much'. Remember, "a little knowledge can be dangerous" (or however that goes).

Panic mode can be self perpetuationg. Nancy has an interesting philosophy about dealing with the unknown and 'what-if's' that basically says 'go with what you KNOW now and don't think about the unknown until you have more information'. Unfortunately, that is much easier to say, and even agree with, than to DO, BUT it seems to be the only logical choice.

Hopefully Nancy will add further enlightenment. Searching for one of her posts could take a while... BUT, at least that would take you mind off the negative for a while.

And don't forget that the Lovenox WILL protect you while you wait for more information and a better understanding of what is going on.

FWIW, I do understand where you are coming from and I wish I could do more to help you cope.

Keep the Faith,

'AL Capshaw'