There must be something I've missed .........

[lance]

My warfarin manager is the best anywhere, she is well educated and has a wealth of experience with ACT. So I'm flummoxed by a recent turn in events.

I've taking 70.5 mg of warfarin since Oct. 6 resulting in readings of 3.2, 3.5, 3.2, and 3.3 yesterday.

The weekly dose for each of those reading was--7.5, 10.5, 10.5, 10.5, 10.5, 10.5, 10.5 totalling 70.5 for the week.

When my reading was 3.5 I was advised to take a weekly dose equaling 73.5. I stayed at 70.5 for the week because I didn't want to increase it when I was at the top of my range. I was in an upward trend anyway. I think I posted about this at that time.

Yesterday's reading was 3.3 and I said I wanted to take 10.5 on Monday and 10 each day for the following 6 days equaling 70.5--less pill splitting.

When I asked why I was told "when we make a one-day dose adjustment we are not changing the total weekly dose. Alternate one day 10 and the next 11 will even out to 10.5 once daily. That increases my weekly from 70.5 to 73 mg a week. I think she must be referring to the dose adjustment made on Sept. 29 when my reading was 4.2 and my weekly dose was reduced from 75.5 to 70.5.

I don't want to fall out with her and wish I could understand why she wants the weekly dose increased when I'm in range. It seems to me she feels my dose should be 73mg regardless of the INR result.

I'm sorry this is so long, perhaps I'm too hard-headed and can't understand the reasoning. I'm back swearing at warfarin again. It's my Nemesis that's for sure.

Any insight will be greatly appreciated.

 

[Karlynn]

I don't know what to tell you. I don't know why doses are being changed when you're in range. ?????

I'd stay on the same dose. In reality the .5 matters hardly at all with the amount you take. I'd do 70/week and leave it at that.

 

[Ross]

If your in range, it's not trending up or down, stay where you are. Let little miss manager throw a fit.

 

[Bina]

Nope, there is nothing that you have missed. Your INRs are perfect.
You know what you are doing and it seems that your doc has a problem with that. Some docs have a power trip thing going on.
I totally agree with the dose you have figured out....10 mg for 6 days and one day of 10.5

 

[lance]

Thanks everyone ....................

Thanks everyone ....................

Karlynn, it's not a .5. She wants the weekly dose to be 73 not the 70.5 I have been taking.

Ross, I have a lot of respect for her and it's uncomfortable to find myself disagreeing with her. May be in the final analysis the adjustment won't matter. I'm trying to not be hard headed but I feel we're two ships passing in the night. Maybe like doctors she could fire me for not taking instructions.

Bina, I'm pretty happy with the range I'm staying in--it doesn't get any better than it is. Maybe a little knowledge is a dangerous thing.

My I'm having fun playing with my smilies.

 

[Bina]

I have the "knowledge" issue with my cardio. He is VERY perturbed that I belong to this group and that we consult and educate each other. When I mentioned PVC and PAC he rolled his eyes and asked "where I got that from?"
He has said that I am free to go to another cardio if I don't trust him.
My GP is the opposite....very supportive.
We don't need to feel "small" with our doctors. Please stay strong and positive.

 

[Karlynn]

The reality is - most people on long-term Coumadin use should be able to learn to manage their own dosing. It's not rocket science and it's safer when combined with home testing. If diabetics can manage their insulin dosing, I'm not quite sure why the "professionals" in the US get so bent out of shape if you question their dosing on Coumadin. Last time someone became upset with me for questioning their dosing directions I asked them how long they'd been dosing people. They stopped arguing when my time on Coumadin was over twice their experience.

There's no need for her to increase your dose. If you let her have her way it is not doing you or her any favors. There's no logic behind her increase. Your INR will go up and she'll decrease your dose again.

 

[Ross]

Lance with my teeth extraction ordeal, I had a dilema having to choose between listening to the doctors or doing things for myself. By listening to them, I ended up in the ER 2 times within 3 days of each other. This last time, I told them what I was going to do, did it and while I risked a stroke for 3 days, I didn't need to return to the ER. Sometimes you just have to believe in yourself.

 

[lance]

I'm sitting on the fence ....................

I'm sitting on the fence ....................

asking myself is 2.5 mg worth causing an issue over. This a.m. my sister asked me what would happen if I made the requested increase and there isn't any answer I could give.

My manager has lots more experience than I have and manages about 70 patients that she taught to use home monitors. The only reason I have mine is because of her. My PCP has supports what I'm doing to the extent that he told my spouse I was capable of doing his ACT. He has even supported my judgement over the nurse in his office when we disagreed--saying I know more than her. In that case I knew I did so "dam the torpedos, full steam ahead". I've prevailed over two dentists and one surgeon when they disagreed with me over ACT. Disagreeing with my manager is something I never expected to experience.

What's happening with my manager is not logical and I'm second guessing myself. It certainly is a judgement call: both of us are probably correct in our view, I just don't understand hers.

Thanks for your input. For now I'm staying on 70.5 mg per week but it's not something I care to boast about.

 

[Karlynn]

You have a great deal of respect for your manager, and that's great. Like many of us have/had a great deal of respect for our parents, sometimes their advice was not correct.

Next time you talk - just point blank ask her "Why did you increase my dose for an INR that was at the upper end of my range?" and see what she says. I just don't understand it. If she gives you a logical answer, post it here. It's not like you were trending downward. And even if you were, a few mgs/week wouldn't make you swing below range most likely.

Maybe she was just having an off day. Don't feel bad about occasionally questioning someone you know has a lot of knowledge. We are all human and we all make mistakes. In the end - it is your life, your body. In another year - you will know more about how your body behaves with adjustments than she does.

 

[Ross]

On the flip side, you could do the increase, see for yourself what the change is, then report that just the same. If you were trending up or down or out of range, I'd worry about little things, but that's not the case here. The case is, Why change a dose for an in range INR? Nothing more.

My child, stop punishing yourself. Either way you go is going to be right, but one idea will reign superior.

 

[Bina]

Lance, you describe your ACT manager as "well educated".....that's great; but does she have common sense??
Don't doubt yourself, you know what you are doing.

 

[lance]

Thanks again for your response and interest

Thanks again for your response and interest

Karlynn,
This is how "the situation" began.
INR 3.5 on 70.5 mg per week. Each time I question the decision the answer doesn't make sense. She seems obsessed that my dose should be 73.5--it's a mystery. So via e-mail we've been discussing the issues. Spouse says I should phone her so to-morrow I will. First of all I thought my math was wrong but that isn't the case.

Bina, Yes, she really is. She holds an MScN based on her work with home monitoring. She manages a lot of other blood related problems as well at a major Toronto Hospital.

Ross, Yes that's occurred to me too. Go my merry way and stay on the same dose=70.5. You know how I feel about ACT. That makes it doubly hard to do what she says. I didn't think I was trying to be superior--maybe I am. I just want my ACT in range. It ain't broke so why fix it and perhaps cause more problems down the road?

 

[Freddie]

Hey there Lance; I know, I should be the last one replying to an INR problem

I just wanted to wish you luck on getting an explanation.