pellicle
Professional Dingbat, Guru and Merkintologist
pardon me for not going over it in such detail.
The table was meaningless IMO without dose ...
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Warfarin Protocol Initiated!
- Thread starter Seaton
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The table was meaningless IMO without dose ...
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pellicle
Professional Dingbat, Guru and Merkintologist
j
not as simple to read as a table IMO (I do like to make it easier for the reader who is answering my questions out of good will rather than harder), importantly it doesn't show the fuller history.
7/04/2024 | 2.1 | 6.50 |
14/04/2024 | 2.2 | 7.00 |
21/04/2024 | 2.6 | 7.00 |
28/04/2024 | 2.9 | 7.00 |
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Clinic blood draw today (Tuesday): INR now 1.3
A drop from last Thursday's 1.4
New dosage schedule given:
They showed me how to self-inject and let me do my first dose. Given 6 days' supply of heparin syringes.
Tonight I was counting out my warfarin tablets into my pill box, when I suddenly realised I was almost out of pills! How time flies. I'd better stock up. Will order more tomorrow.
Onwards to getting in range.
A drop from last Thursday's 1.4
New dosage schedule given:
- 9mg tonight
- 9mg tomorrow
- 7mg Thursday
- Clinic INR test Friday
They showed me how to self-inject and let me do my first dose. Given 6 days' supply of heparin syringes.
Protime, you were correct!
Tonight I was counting out my warfarin tablets into my pill box, when I suddenly realised I was almost out of pills! How time flies. I'd better stock up. Will order more tomorrow.
Onwards to getting in range.
pellicle
Professional Dingbat, Guru and Merkintologist
I really am not surprised ;-)
welcome to the system
my system is to always keep at least 1 bottle in reserve, as soon as I use one I go into the chemist and buy another.
However its a bit better, because I have a selection of three bottles; 1, 3 and 5mg. So its rare that all three are out at the same time. When I go in I always buy 1 of each size.
I'm also driven by my friend who's a pharmacist who often regaled me with stories of entitled pompus people ranting at him at 5:01pm (closing time) on Friday needing to get their script filled because they ran out.
Best Wishes
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That is unfortunate, but not surprising. I am doubling down on my assertion that the blindfolded monkey throwing darts would beat this particular clinic.
Crossing fingers that this is the case. Now that they have finally gotten serious about increasing your warfarin dosage, I think you will be on your way to getting in range soon. On the other hand, let's wait and see what goofy thing they do next once you are in range again.
Hoping they don't drop you down to 5mg again.
pellicle
Professional Dingbat, Guru and Merkintologist
carolinemc
Well-known member
Yeah, I go to a reliable lab, that is located where people also have cancer treatment. Been doing great. they use the same home devices as many here do. and when I am having issues, we catch while I am there and dose accordingly and the return trip. Heparin throws you a monkey wrench and takes time to get back to normal. And good you have a pill box. I have used mine for several years. Keep hanging in there.Clinic blood draw today (Tuesday): INR now 1.3
A drop from last Thursday's 1.4
New dosage schedule given:
When the clinic called with my new INR figure at midday, they asked me to go back again in the afternoon to have a heparin (Dalteparin sodium – Fragmin®) injection. They want me on the Dalteparin every day until my next blood draw in three days' time, or until I am in range, should I not be by Friday.
- 9mg tonight
- 9mg tomorrow
- 7mg Thursday
- Clinic INR test Friday
They showed me how to self-inject and let me do my first dose. Given 6 days' supply of heparin syringes.
Protime, you were correct!
Tonight I was counting out my warfarin tablets into my pill box, when I suddenly realised I was almost out of pills! How time flies. I'd better stock up. Will order more tomorrow.
Onwards to getting in range.
Seeing as I have contradicted myself and continued to post my ongoing newbie-to-warfarin INR readings anyway, I thought I’d continue until in range and stable, chiefly as an example and reference for any others new to all this.
Clinic blood draw today (Friday): INR now 1.7
An increase from last Tuesday's 1.3
New dosage schedule given:
I’m to continue daily Dalteparin (heparin) until next INR test, midday Monday. Will stop once in range. I’m imagining I should have limped into range by Monday.
In other news, I’ve ordered my Coagucheck INRange starter pack (with 6 free test strips). Hoping to get it sometime next week.
Clinic blood draw today (Friday): INR now 1.7
An increase from last Tuesday's 1.3
New dosage schedule given:
- 10mg tonight
- 9mg Saturday
- 8mg Sunday
- Clinic INR test Monday
I’m to continue daily Dalteparin (heparin) until next INR test, midday Monday. Will stop once in range. I’m imagining I should have limped into range by Monday.
In other news, I’ve ordered my Coagucheck INRange starter pack (with 6 free test strips). Hoping to get it sometime next week.
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Hi Seaton,
I had very similar issues when I first started warfarin with my Anti-coag clinic in the UK.
I was around 1.7 to 1.8 and they were only increasing my weekly dosage by 1mg or so (when I was taking 5mg a day or so). After four weeks of this and them wondering why we are still not rising, I took matters into my own hands. I raised it by 5 mg one week, then another 5 the next and voila, I was in range for the first time. I then proceeded to do this myself for a long time. Eventually I told them, they looked at my machine and at their records and since the improvement was so visible, they realised I was doing something right. Now they accept that I self-test and self dose. They only ask me for the dose I take any given month to update their system, so it is there in case there is an emergency.
Obviously, it takes a lot of self confidence to depart as much from clinical advice as I did. But sometimes you need to take your own health into your own hands. This is what I did when I first started warfarin almost 2 years ago now and havent looked back since. My clinic are very happy with our relationship now and so am I.
I had very similar issues when I first started warfarin with my Anti-coag clinic in the UK.
I was around 1.7 to 1.8 and they were only increasing my weekly dosage by 1mg or so (when I was taking 5mg a day or so). After four weeks of this and them wondering why we are still not rising, I took matters into my own hands. I raised it by 5 mg one week, then another 5 the next and voila, I was in range for the first time. I then proceeded to do this myself for a long time. Eventually I told them, they looked at my machine and at their records and since the improvement was so visible, they realised I was doing something right. Now they accept that I self-test and self dose. They only ask me for the dose I take any given month to update their system, so it is there in case there is an emergency.
Obviously, it takes a lot of self confidence to depart as much from clinical advice as I did. But sometimes you need to take your own health into your own hands. This is what I did when I first started warfarin almost 2 years ago now and havent looked back since. My clinic are very happy with our relationship now and so am I.
The clinic's dosing still seems weird: the objective is to get in range and take a consistent dose, but they seem to never dose the same amount two days running! With Warfarin taking 3 days to take full effect in the blood stream, it is very difficult to manage it with erratic inputs. At least you are on Heparin in the meantime, and have your own meter coming. Power to the People!
10 9 8 ???
WTF ?
I wouldn't have ANY confidence in this clinic. They don't seem to have ANY idea what they're doing.
If you need 10, fine - in three days or so, you'll be in range -- then start to drop lower because your dosing is less.
If you can self test, get a meter (I can help you out with this), do your own testing and, for god's sake, do your own management. There are people here who can help you (particularly Pellicle). If you HAVE to use this clinic to get your prescriptions, you may have to fool them into thinking that they're doing a great job so you can get your next prescription for warfarin. But you may find a doctor who trusts your ability to test and manage and has no problem prescribing for you.
This clinic doesn't appear to be clueless.
WTF ?
I wouldn't have ANY confidence in this clinic. They don't seem to have ANY idea what they're doing.
If you need 10, fine - in three days or so, you'll be in range -- then start to drop lower because your dosing is less.
If you can self test, get a meter (I can help you out with this), do your own testing and, for god's sake, do your own management. There are people here who can help you (particularly Pellicle). If you HAVE to use this clinic to get your prescriptions, you may have to fool them into thinking that they're doing a great job so you can get your next prescription for warfarin. But you may find a doctor who trusts your ability to test and manage and has no problem prescribing for you.
This clinic doesn't appear to be clueless.
Looking at your post again, I think the issue is that your clinician seems to think that 7mg is your maintenance dose. But how can he know that with confidence? By definition, your maintenance dose is the one that keeps your INR between 2-3. That is a different number for everybody and can also vary over time.
pellicle
Professional Dingbat, Guru and Merkintologist
I'd love to know why ¯\_(ツ)_/¯
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I'm very glad to hear that things are on the way up.
There is not enough data yet to predict that 7mg will do it. At this point, I'd suggest it's going to probably end up being a little higher than that to put you in range. Recall that at 7mg, 7mg, 7mg, 8mg, 8mg, brought you to INR of 2.0. That is when the brilliant decision was made to drop your dosage by 40%, which is totally inexplicable and led to INR of 1.3. But, based on that limited data, I'd wager that you'll end up being at least a little north of 7mg/day to get in range, when the dust settles. But, no real need to speculate. Just go with the INR readings and dose accordingly.
The updates are greatly appreciated. Thank you.
That's sensible.
That's completely bonkers. He should not be aiming for any particular dosage. He should be aiming for your specific INR target, regardless of the dosage of warfarin it takes to get there.
There is not enough data yet to predict that 7mg will do it. At this point, I'd suggest it's going to probably end up being a little higher than that to put you in range. Recall that at 7mg, 7mg, 7mg, 8mg, 8mg, brought you to INR of 2.0. That is when the brilliant decision was made to drop your dosage by 40%, which is totally inexplicable and led to INR of 1.3. But, based on that limited data, I'd wager that you'll end up being at least a little north of 7mg/day to get in range, when the dust settles. But, no real need to speculate. Just go with the INR readings and dose accordingly.
The updates are greatly appreciated. Thank you.
pellicle
Professional Dingbat, Guru and Merkintologist
totally agree
personally I think there is enough to support at least 9 or perhaps 10mg
so, going back we find:
20th of April, first dose was
which on the 23rd was
ok ... only 3 days you say (and I agree ... somewhat )
The 25th was
which is at the bottom of the range, but rather than leave it, which was bewildering, they lowered dose (as you properly cited the typing monkeys).
not unpredictably the 30th it fell
3rd May was
then ...
and then
I think we have had enough measurements for any twit who understands the basics to have got the message that it needs to be more than 7 (assuming the target is 2.5 not 2.0) and probably 9 or 10.
So after 6 measurements and about 3 weeks all they've done is hover around what would have happened if they'd just administered 7mg (which seems to be the magic number they have in their heads). As you observe, its INR that matters, not milligrams.
At least that's how I see it.
PS: personally theory. They are so worried about going over INR=3 (which is actually still very safe) that they are willing to see the patient require heparin to avoid that. I can only but speculate on the "why" of that. Given what is well established
heck they could comfortably "overshoot" to INR=4 and titrate down with basically no added risk.
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I'm definitely in that camp. Better to overshoot a little and titrate down. When 7mg, 7mg, 7mg, 8mg, 8mg resulted in INR of 2.0, they should have kept him at 8mg for a few more days to see if it kept climbing. Having 5 consecutive days at 8mg would have provided some good data. 2 days of 8mg, following 3 days of 7mg only brought him to the lower end of his range and there was little risk that continuing 8mg would have overshot above 3.0. If it did overshoot, then no big deal, just titrate down. Being a little over 3.0 is no big deal. Spending weeks at 1.3 or 1.4 is a big deal. As to why they decided to drop from 8mg to 5mg? We may never know, but it sure strikes me as a completely incompetent decision. Having said that, their most recent dosage for the next 3 days of 10mg, 9mg and then 8mg is more reasonable.
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pellicle
Professional Dingbat, Guru and Merkintologist
agreed, especially if they then take that data and don't then use it to rationalise "we'll move down to 7 next"
but I'm just some random guy on the internet.
I'm still up for "it'll be 9 or 10mg" when the dust settles.
BTW, I found this interesting and slightly amusing document on an NHS site here. It is among the few who cite Fennerty (1984) and then bother to correct that with something "more recent" Gedge et al (2000) as the basis for a document that's written in 2021.
I must say this isn't much to overturn Fennerty
Gedge et al (2000) suggested that the commonly used Fennerty (1984) initiation protocol has been poorly validated in older adults and can result in significant over-anticoagulation of patients over 65 years. This has been supported by in-house audit. Gedge et al (2000) tested an alternative regimen for patients over 65 years which lead to a reduction in over- anticoagulation (INR more than 4.5), an increased amount of time within the therapeutic INR range and fewer omitted doses of warfarin.
which amusingly predates the establishment of the INR paradigm. Good to see that research is being read and used in a timely manner...
Even this review (one of the few to seemingly cite Fennerty) is over 10 years old now.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8454262/
Authors' conclusions
The studies in this review compared loading doses in several different situations. There is still considerable uncertainty between the use of a 5 mg and a 10 mg loading dose for the initiation of warfarin. In the elderly, there is some evidence that lower initiation doses or age adjusted doses are more appropriate, leading to fewer high INRs. However, there is insufficient evidence to warrant genotype guided initiation.
{pellicle: bolding mine}
I'm not certain, but I don't think Seaton is >65yo ... so still Gloucestershire Hospital's alternative isn't valid either (wrt the actual patient).
I'm sure no clinicians actually read this stuff ... just some administrator who's perhaps interested.
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pellicle
Professional Dingbat, Guru and Merkintologist
done ... a beer to the winner ;-)
Hahaha... well, I should say 7mg just to play devil's advocate
But suppose 9mg (ish) could be the sweet spot... Then again, what do I know!
*I don't drink, but I should buy you all a beer, anyway.
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