Update on my wife - good news, bad news

[traig]

Hi all. I posted a while back after my wife had two mech. valves put in and the rehab hospital couldn't get her into a theraputic INR range. Many of you wrote here and privately and helped reassure me and my wife and I am still grateful.

You'll be glad to know that she was discharged from the hospital in the first week of August and went into the care of a coumadin clinic run nearby as part of a popular cardiology practive. They seemed to take the approach that Al and others endorsed: small changes, analysis once a week.

So the good news is that slowly my wife was inching closer and closer to the desired range for her INR, which we figure is around 3 to 3.5. They've been making tiny adjustments to get her up over 3, and last week she was at 2.8. She's on 4 mg a day.

The bad news is today we went in and she came out at 1.8. My wife was very upset and one of the cardiologists there today came in and spoke with us. He was great and we discussed what might have happened. It's a bit of a mystery. My wife's diet has been largely consistent over the past week, especially with regard to leafy greens and the like. My theory is that it's related to exercise: starting a few days ago, my wife began taking walks of 20-30 minutes twice a day as part of her rehab ... and it gives us a chance to take our 4-month-old twins out for a walk together. Before the weekend the most she did was take a couple of 10 minute walks around the house.

The doctor agreed, saying that he doesn't think Lovenox is necessary at this point, and that it's likely that the decrease in INR is due to my wife becoming "healthier" in general (i.e. recovering from everything). They upped her daily to 5 mg, despite the doc's acknowledgement that as far as protocol is concerned it's a rather large increase (25%). My wife, however, is still upset and concerned about the possibility of stroke, and is still despairing over how this could have happened. Note: she is on Torprol and they increased her from 12.5 to 25 mg last Thursday, but they said that beta blockers shouldn't have that kind of impact on INR.

Do any of you who have "been there, done that" have any words of wisdom for us??

PS - our twins are four months old and doing terrifically, and mom is VERY happy to be back with them.

 

[Karlynn]

Thank you so much for the update.

Your wife's dosage needs will most likely increase as she continues to heal. As you mentioned, exercise is part of the culprit, as is the fact that the better she feels, the more she eats. Plus her body is starting to work better as well, so she's processing the dosage faster. I think it's all probably a good sign.

 

[geebee]

Exercise will cause the INR to fall so that may be the culprit. I think changing to 5mg should be fine but I would definitely retest in 4 days to see where she is.

1.8 is pushing the danger level. I will let others make comments about bridging therapy but I would personally worry if I were at 1.8.

Glad to hear she is doing well otherwise and feeling well enough to exercise and enjoy the time with her family.

Take care.

 

[Guest]

This is exactly what I would expect to happen. It is related to feeling better, getting more exercise and eating better. I had a letter to the editor about this published in the American Journal of cardiology.

 

[Ross]

Bottom line---NORMAL! Relax, but try your best to keep it over 2. She's probably going to bounce around a bit until her body is back to proper excercise and diet, so expect some fluctuations for a little while. Nothing to freak over though.

 

[Mb]

Hello:

Not to scare you....but please keep on top of this. My husband had a TIA at 1.8 this past February. He also had a small stroke in January (very small). He is a dual valve patient, but also has chronic a-fib. He is VERY careful with his warfarin dosages, so you can imagine our surprise when he went in to find his INR at 1.8 - We've no idea how that happened, as he has been on a fairly consistent dose of the drug for over three years, and it never went that low. (He does think he may have eaten too much of some homemade lentil soup...but I do not agree). He is also 59 years old. She is correct in being concerned, and should be monitored very closely over the next few weeks. By the way, they did not bridge him in any way. - Marybeth

 

[Nancy]

Joe was at 1.8 last week, and this week with some adjustments, he's now at 3.2.

I agree that you have to be vigilant about going that low. That's TIA and possibly stroke or bloodclot range for him, his normal range is 2.5-3.5.

That being said, there are ALWAYS fluctuations in INR, usually they aren't that dramatic, but they always happen.

Joe's Internist does his Protime testing and understands very, very well about the range that is necessary for Joe.

I caution you that not every doctor will pay good attention to INR numbers, either from ignorance or just not caring very much about it.

So YOU and your wife are going to have to be the ones who pay attention.
ALWAYS ask what the INR is with each test, and write it down, and then write down what the dosage adjustment was and what you think happened in your wife's life to cause the the INR change.

That way you will have a running record of how your wife's body reacts to adjustments in Coumadin levels.

Some of the things that change Joe's INR the most are activity levels, either more or less, congestive heart failure (fluid retention) and then the diuresis necessary to get rid of the fluid, and changes (which are frequent) in any of his medications.

It will never be the same for many people, so needs careful attention.

 

[traig]

Thank you all for your thoughts. Rebecca is concerned but I think we're going to stick with the plan for the next couple of days, 5 mg and no bridging...

We have a test scheduled for Friday morning since that's the earliest I thought we'd see the trend or results from taking her to 5mg. There's also another test scheduled for Monday -- I made that appointment assuming we would not change her intake Friday (unless her INR actually goes DOWN).

Al, I checked your site for that editorial but didn't see it.. is it available there?

 

[catwoman]

traig:

Glad to see a post from you. I have often thought of you, your wife & your twins, and hoped everything was going well for y'all.

Like others have said here, a person's INR drops as activity level increases, because the liver metabolizes the anticoagulant much faster and therefore requires more. Many mechanical valvers are put on very low doses of warfarin in the hospital and as they become more active, their dosage is increased. Some folks never need more than 2.0-2.5 mg of warfarin daily. Others, such as mothers of toddlers , will need more. I started out with 2.0 or 2.5 mg daily and now take 6.5. I try to keep my INR between 3.0-4.0.

The 3.0-3.5 range you mention is very narrow and will be more difficult to stay in than 2.5-3.5 (usual range for a mechanical mitral valve).

The increase in your wife's dosage is a little on the high side, but if she continues to increase her activity level, that may offset the extra warfarin.

Our motto here is: You can replace blood cells, not brain cells. It's preferable to be a little "thin" than a little "thick," as some would describe it.

You will probably want to look into home monitoring for your wife's INR levels. There are several companies that provide monitors; QAS (which has a link here) and Raytel Cardiac Services are two that I've dealt with. I've been pleased with both. Because Raytel is in network with United Health Care, I've had to switch from QAS.
Being in charge of my own monitoring gives me, my husband and my family piece of mind.

 

[Guest]

No, sorry. It is not available on line. They own the copyright to it.

 

[Gail in Ca]

Exercise makes a huge difference in weekly dosage. I have stopped exercising regularly for about a month or more, ( Bad Me) and I now take 60mg warfarin weekly, down from 72mg weekly. Only change was no regular exercise. I am going to start making a real effort to start up again, and so expect my warfarin needs to go up.
Gail