steady low rending INR

[LLJ]

HELLO ALL
Happy Easter and Passover
Question: I have found as my intensity of exercise has increased (Traithlon and half marathon training-up to 2 hours a day fairly intense training) My INR has decreased. I had a mechanical aortic valve placed last Aug. Initial dosing was 7.5 daily. As I became more fit it went to 10mg once a week then twice a week 7.5 other days.
Two weeks ago 2.0, last Wed 1.5 and testing this morning 1.2. I took 10 mg Wed and was instructed by my physician to do 10 mg thursday.
Questrion: the on call dr told me to take 15 today-to which I replied"havent I been unprotected since Wed???" He then said he would order Lovenox for my to do today. What the heck????? What is the opinion here?
Help!!!
Laura

 

[Bina]

That INR of 1.5 would surely have warranted a Lovenox shot that same day, and continuing twice daily until you
were in a safe range again.....Grrr, some doctors
I wouldn't take 15 mg today because your INR is rising slowly, which is a good thing, but the fact that
they left you in a danger zone would have me screaming.
Anyway, run (since you like it),and get the Lovenox now.

 

[bdryer]

LLJ

Do you home test? With your active life style I would think you would be a candidate. Home testing would keep you out of the danger zone. Just as you are presently building for an event [fitness], inevitably you will taper. What's the flip side? Too high an INR. Bina is an expert, she can guide you on home testing.

I'm 5 weeks post op and have been > my level of activities. At the same time my body is ridding itself of Amiodarone. Both drive a lower INR. When I last tested I was at 1.9. I'm going to the lab once a week so they should be able to stay on top of it.

I'm sporting a shiny new On-X AV. So far the study for maintaining us On-X folks at an INR of 1.5 to 2 is successful. Hence I'm not freaking if I drop a little more then the present 1.9. I'm not naive either and if I do drop further on the next weekly test, I will ask the managers of my INR if I should go for a Lovenox shot or two. My present target is 2.0 to 3.0.

Good luck

 

[JimL]

Wouldn't it make sense for you to dose yourself? Let whoever tell you whatever to take, and then figure out for yourself what you will really take. They moved you from 7.5 daily to 10 once a week, then twice a week. Take whatever you think is right, whether 3X 10 a week, with 7.5 the other days, or 4X a week. Next week you'll have an even better idea of where to go from there. I should say that I have next to no experience with lovenox. Keep in mind that the INR is actually measuring where you were at 3 days ago, since the coumadin you take today takes three days to take effect. I've found over the years that I'm very sensitive to small changes; even if the numbers would indicate a larger change, I rarely change more than 1 mg a week. You may be very different, especially doing all that training.

 

[LLJ]

I test weekly since the numbers have been bouncing around.(I have my own unit) and yes I have been dosing myself accordingly-but this drop just threw me for a loop. I dont understand why my levels did not respond. I started out with 7.5 daily and as I started to exercise more, increased to 1x week 10mg. As the training has intensified I increased to 2x week 10mg in response to lower INR.(and admittedly I did not curtail my daily salads and greens or one glass of red wine each night-all I have been doing for months now)
Bina _i got the Lovenox and injected today with 80ml and was told to take 10mg warfarin tonight -which I did. When do you think I should test again?
Laura
Thanks guys!!!!!

 

[Protimenow]

I got my St. Jude valve nearly 20 years ago, and don't recall EVER dosing with Lovenox.

I don't know how long it actually takes for a dangerous clot to form, so I'm not sure if the use of Lovenox whenever an INR drops below, say, 1.8 isn't just a bit hyperreactive. I've read about people who dropped their INRs into the 1s for surgeries, and didn't die of strokes.

Does anyone know if running to a doctor or pharmacy for lovenox whenever the INR gets into the 1s may be a bit of an overreaction? (I realize that clots - anywhere - can form quickly -- this is why cuts close up -- but does this really happen as quickly on the surface of man made valves?)

Just curious....I'm not advising ANYONE either way.

 

[Bina]

I test weekly since the numbers have been bouncing around.(I have my own unit) and yes I have been dosing myself accordingly-but this drop just threw me for a loop. I dont understand why my levels did not respond. I started out with 7.5 daily and as I started to exercise more, increased to 1x week 10mg. As the training has intensified I increased to 2x week 10mg in response to lower INR.(and admittedly I did not curtail my daily salads and greens or one glass of red wine each night-all I have been doing for months now)
Bina _i got the Lovenox and injected today with 80ml and was told to take 10mg warfarin tonight -which I did. When do you think I should test again?
Laura
Thanks guys!!!!!

Laura, I'm glad that you got the Lovenox shot....better safe than sorry.
Normal protocol is to take Lovenox daily until the INR has reached 2.0 or higher.

In my case, at 4 weeks post op my INR dipped and I needed 3 or 4 days of Heparin and Lovenox before I was back in
range. Hospital tested me daily until I was over 2.0 again. These days, since I have a home tester, I would
also test daily while in the danger zone until a safe INR is reached....then weekly is perfect.
Best wishes !

 

[ALCapshaw2]

I'm thinking that Clot formation can take several days BUT one should ask their Doctor(s) for a more knowledgable opinion.

A 'common' protocol for Lovenox Bridging, is to continue the appropriate (weight based) dosage, twice a day, until your INR is back within your Target Range. Note that Lovenox is both Fast Acting and Short Acting, 'wearing out' after about 12 hours.

'AL Capshaw'

 

[LLJ]

Protimenow: I guess I am sensitive to the possible dangers as my mom (who also has a new valve) had a TIA which temporarily blinded her and left her with mild residual vision problems. Now her issue is compounded by a fib. however this occured when her INR was dropped to 1.4 with no prescribed Lovenox bridge for a minor post surgerical procedure.
Thanks Al and Bina for the info:I am confident I will be able to get the numbers in line. A little knowledge may be a dangerous thing,but as a PT who treated CVA patients for many years--I am alittle wary.....

 

[Protimenow]

Please understand that I'm not trying to tell anyone what to do or what not to do. It's probable that age and other factors may make a 1.4 more risky for some people than it does for others, and there's no good (or safe) test that I know of that will help predict this. I was just speculating.....