What if my PT-INR is very low or very high...?

[archkre]

What should I do if a given day my PT-INR is very low or very high, besides trying to avoid a panic attack...?
By the way they just let me know now it went to 4.7!!!!!!
Thanks a lot!

 

[catwoman]

Daniel:
Do you home-test?

I don't worry too much about an INR at the high end. I do, however, worry about one at the low end. My INR is usually 3.4-4.0 or so.
If I had an INR that was extremely low, I'd retest. If 2nd test is low, then I'd bump up my dosage based on Al Lodwick's dosing chart and retest in 7 days.
As far as being "too" high, it would depend on how high it is and why it's high. I might cut back my dosage a tiny bit for one or two days -- or just go and have a couple of spinach salads or several long walks.

To avoid going on an INR roller-coaster, I avoid micromanaging my dosage.

 

[Karlynn]

Marsha gave good advice - particularly on retesting to confirm. Even if you get your test done at a lab or clinic and pull a low or high INR, have them retest too. (If it's a venous draw and not a finger stick, that usually means a trip back to the lab.)

Also what is considered too high and too low is subjective depending on who you're talking too. I'd much rather be too high, than too low. For me an INR up to 5 is something I handle myself (dosing) w/out calling my cardio. If it's going towards 6, then I call and we discuss what I should do. If your INR is, let's say, 6 and you are having nose bleeds or gum bleeds, that most-likely requires more action than a 6 w/ no signs of bleeding.

If your range is up to 3.5 and your Coumadin manager freaks out at a 4.0 and tells you to hold a dose - you need to get a new manager. The most important thing is to have a Coumadin manager to work with that really knows how to do it. There are a lot of Wanna-be's out there.

What is done as far as dosing for out of range INRs really should be measured against how much Coumadin you take. I take a fairly high dose (10 mg). If I hold a dose, my INR drops like a rock - an okay thing if I'm at 6 or above, a bad thing if I'm at 4.0. Someone who only takes 2 or 3 mg a day has much less harsh a drop.

As far as being low. I call my cardio at 1.5. I test weekly, so those low INRs are few and far between. Many people prefer to get some Lovenox going if their INRs are low and are having hard time raising it.

As far as the "freaking out" goes. Read Al's thread on Finally Found Someone that Bled to Death from a Cut. His point is that while bleeding may occur with a too high INR, it's not the end of the world. Low INR's are more of a concern, but if you're low for a few days or so, you shouldn't freak out.

 

[archkre]

Daniel:
Do you home-test?

I don't worry too much about an INR at the high end. I do, however, worry about one at the low end. My INR is usually 3.4-4.0 or so.
If I had an INR that was extremely low, I'd retest. If 2nd test is low, then I'd bump up my dosage based on Al Lodwick's dosing chart and retest in 7 days.
As far as being "too" high, it would depend on how high it is and why it's high. I might cut back my dosage a tiny bit for one or two days -- or just go and have a couple of spinach salads or several long walks.

To avoid going on an INR roller-coaster, I avoid micromanaging my dosage.

I get my PT_INRchecked at Quest(Lab), and this is my first time the value goes to hell!
I've just called my cardiologist, left the message in the voicemail , but don't know what to do untill she calls back!
Should I be feeling bad or what?
Should I go to the kitchen and fix a big spinach & aspargus & avocado and extra broccoli salad with canola oil and eat it quickly?
"Micromanaging"...what is that??
Thanks!

 

[Ross]

Take a big deep breath and relax. It's not that bad at all.
How often are you being tested?
What is your daily dosing schedule?
Do you know what range your supposed to be holding?

Whatever you do, if they tell you to hold your dose or two, DO NOT DO IT or you'll end up in the flip side and too low.

You'd have to eat an awful lot of greens to make much of a dent in it. At this point, I'd maybe hold a half dose and eat some extra greens for the week, but really need to know how your being dosed and tested now first.

 

[catwoman]

By "micromanaging," I meant that I don't test more frequently than once a week -- it may be 10-12 days apart sometimes -- and then change my dosage to keep it rock steady at 3.5.
My guess is that newbies to warfarin are more apprehensive about INR values that longtime patients. We don't react drastically to changes in our INRs and continually increase/decrease our dosage, like a knee-jerk reaction.

Part of it is that we've recovered from surgery and are back to an activity level that's normal for us. Therefore, our INR is going to be more constant, except when we are under the weather, change our eating habits drastically or start/stop other medications.

 

[archkre]

Catwoman: I am really new at this, I was operated 22 days ago, and I am already
working normally, but neither my cardiologist, surgeon nor primary doctor explained anything of these issues to me!
All I know is due to my fellow mates of this forum.
What I don't understand at all is that you test yourself, you change your dosage at your will!
Isn't that dangerous?
Shouldn't all that be under the strict supervision of the physician?
Thanks a lot!

 

[catwoman]

Daniel:

My PCP approved my getting a PT/INR home testing machine several months post-op. (He has at least 2 other patients with machines.)
I doubt that he would let all his warfarin patients do home testing and adjust their own dosage.

I've been testing at home for 2+ years and have been adjusting my own dosage for nearly 2 years. Much easier than calling in test results to my PCP and him telling me what to do, or worse, going to his office every week and taking time off from work, juggling appointments with vacation time, etc.

It's relatively easy to learn how to adjust your dosage, because you usually increase/decrease your dosage by percentages -- such as 10%, 15%, 20%, according to an algorithm chart that you can buy from Al Lodwich here (a pharmacist at a hospital in Pueblo, CO., and a certified anticoagulation care provider). The chart uses the same info that my doctor's office follows.

For instance -- and this is only hypothetical -- if I were to test at 5.5 two weeks in a row and I couldn't determine why (meds, foods, activity level constant), I might cut my dose by 50% for one day **and** reduce it by 10% as a starter.
I take 6.5mg daily. So, I'd multiply 6.5 X 7 (days a week) and get 45.5mg for my total weekly intake. Reduce that by 10% and I get 40.95. Let's call it 41mg. Divide that by 7, and you get about 5.9 daily. Will taking 6.0mg X 7 be OK? Dunno. I'd chance it and see what happens when I retest in 7-10 days. Or I could take 6mg X 6 and then 5.5 on one day, for a total of 41.5mg weekly. I prefer to take the same amount every day, instead of an every-other-day schedule.
I seldom have to adjust my dosage.

Like many others here, I have an incentive for home-testing and learning to adjust my dosage. It sames a lot of time and $$, and I am more in charge of my health.
My PCP writes my Rxes. I take my records to his office every couple of months and his employees photocopy them for my file.

Much of it goes back to the patient-physician relationship -- whether the doctor thinks you understand your condition, how warfarin works, etc.

 

[catwoman]

BTW, the PT/INR home testing machines require an Rx from your doctor, unlike glucometers for diabetics. And they are more expensive. My ProTime 3 was $2,200-$2,400, but insurance covered 100% of durable medical equipment when I got it.

 

[Christina]

I understand you being nervous.

I understand you being nervous.

Daniel,

You are already back at work full-time after just being 22 days out of surgery??? Are you Superman, or what? You just had major surgery. Aren't you feeling the least bit tired?? I remember the exhaustion being overwhelming at times and I had to take catnaps often during the day. I hope you are not pushing it to much. Give yourself enough time to fully recuperate, because once at work you know that everyone thinks you are back a full 100% and that's what they expect you give the boss.
I understand you being very anxious about this whole Coumadin thing. It is so scary and I understand because I once was where you are today. In the beginning I also was scared because I was new to this Coumadin thing and had no idea because doctors don't tell you much. I also know now that many doctors don't really know how to correctly manage a Coumadin patient and they go berserk (sp) if a patients INR goes over 5 and many of them right away want you to hold a dose. I've been there, done that, so I know what I am talking about. Personally, if I skip a dose I bottom out, that means your INR goes very low and you'll be in danger of a blood clot or stroke. Those can be deadly. You are in much better shape if you are too high. Believe me when I tell you that you will be able to handle a nose bleed much easier.
I've been on Coumadin for 5 1/2 years and have done my own hometesting and dosing. I don't call my doctor if I don't have to because he drives me nuts, because when I go over 5 he'll have me hold for 24 hours, and God forbid if I go higher than that. Let me tell you, and I need to remind you that everyone is different, but I've been as high as 8.2 without any problems and never have had a bleed. I am not saying I never will, but I am very careful. What I do is eat a huge salad or other green vegies or take a few vitamin K drops (I have them on hand, just in case I need them). I test twice that week just to know where I am. It is such peace of mind to have your own testing device. I love it.
For the rest I keep my vitamin K intake steady every day and my INR stays stable(well, most of the time ) I also want to tell you that INR stands for: "IT'S NEVER RIGHT", so don't sweat it too much. Just be consistant and you'll be fine and you'll be a pro at this in no time.
Feel free to ask more questions.

 

[Karlynn]

Wow, sorry, don't know how I missed the 4.7. Still, not a hugely high #. What is your daily dose now?

Relax, have a lovely salad or glass of V8 juice. As Ross said - do not let them tell you to hold a dose unless you are on a very low dose - like 2.

You will find, as you become more experienced, that just like diabetics can do their own blood sugar tests and decide what dose of insulin to inject, we can also test our INR and decide what to do with our dosage. Any doctor that doesn't think patients should be able to home test doesn't know enough about Coumadin. Sure, there are people who need to, or prefer to have their testing and management done by others. And it's okay if there are some that home test, but call in their INR to an office for direction. But to think that one can't stick their finger and put a drop of blood in a machine must be very upset with how diabetis is managed in this country.

Your INR will most likely continue to flucuate as you heal. Even though you are back at work, your body is still in the first part of healing - so be careful!!!!!

 

[archkre]

Since mine was a programmed AVR I was excercising very hard for 5 or
7 month previous to my surgery to get a very good body shape.(my bycuspid aortic valve was still asymptomatic)
That along with the minimally invasive surgery and the awesome ON-X
valve helped reduce the toughest part of the post-operation.
However I don't take stupid risks!

 

[Guest]

Many docs only manage 10 or so patients on warfarin, so they never get really good at it. I manage 550 people. I saw 450 patient visits this month. It would be extremely rare that I would hold a dose for an INR of 4.7 when the person was not bleeding. You will get the hang of managing warfarin for yourself.

 

[Sierra Bob]

On January 17, my cardiologist changed my INR range to 3.0 to 4.5, up from 3.0 to 4.0 because of my episode of Amaurosis Fugax (blood clot in the eye causing blindness). This was after a carotid ultasound, a cardiac echogram and a stress test. So I certainly wouldn't worry about a 4.7!!!

 

[Sierra Bob]

I should have added I also self test weekly and manage my own warfarin adjustment. I've been doing this since February, 2001, with my cardiologist's blessing. I use 4mg and 5mg tabs, normally taking about 63mg per week. I can easily change the daily or weekly consumption by adjusting the mix of 4s and 5s--two 4s, two 5s or a 4 &5. I've yet to call my cardiologist to discuss a change in my dosage in six years.

 

[catwoman]

Since mine was a programmed AVR I was excercising very hard for 5 or
7 month previous to my surgery to get a very good body shape.(my bycuspid aortic valve was still asymptomatic)
That along with the minimally invasive surgery and the awesome ON-X
valve helped reduce the toughest part of the post-operation.
However I don't take stupid risks!

I would chalk up your post-op recuperation to your pre-op condition and the minimally invasive surgery.
Type of valve would have little effect on the physical aspect of recovery.

Those of us who have shortness of breath, extreme fatigue, enlarged heart, cyanosis before surgery take much longer to recover. I had all that, and it was probably 9 months before I felt fairly "normal" again. At nearly 2 years post-op, my left atrium was normal size again.
This is why we recommend/urge/advise people to have surgery BEFORE they begin to experience symptoms!

You took a very smart approach pre-op to your surgery. Good luck with the rest of your recovery.

 

[archkre]

Yes, and that was thanks to my wise cardiologist, Dr Sanzobrino, of the
Hollywood Memorial Hospital in Florida, who insisted and insisted....!
At tht moment my point was: Why would I have a heart surgery if I feel perfectly normal?
Thanks god she could convince me!!

 

[Blanche]

Daniel:
As Ross said, take a deep breath, and relax. You are brand new at this! Your INR will fluctuate a great deal at the beginning as your system gets used to the new procedures. If you like spinach salads or other veggies and drinks high in vitamin K, now would be a good time to indulge yourself. If you don't like these things, pass on them. Albert does not take Vitamin K when his INR is higher than required, and would not recommend this practice. We know alot about the half-life of Coumadin, but very little about the half-life of Vitamin K....which also makes anticoagulation a bit difficult to monitor.

Since you have no training in anticoagulation and are new to this, please do not make any changes on your own. You must wait until the person who regulates your Coumadin gives you instructions. This should happen the same day as the test. If not, call, and keep calling until you get an answer.

My husband has been self-testing for 5 years. He's had quite a few INR results of 4.7 or above. His range is 3.0-4.0 because of other medical conditions.

As time goes on, you will become more informed about your condition and coumadin/anticoagulation management. May I suggest that you start with Al Lodwick's site? www.warfarinfo.com. As questions pop up, bring them here. You have many who will help at your finger-tips.

Blanche

 

[DavesMom]

Hi Daniel,

I'm normally a lurker but have to add my voice to those telling you to relax. 4.7 is not bad and being on coumadin is no big deal. In fact, as of today my mechanical valve and I have been together for seven years (we had a nice dinner to celebrate our anniversary) ; ) and coumadin has yet to be a problem. There have been a few worrisome fluctuations (I've been as high as 5.1 and as low as 1.4) but so far no ill effects.

Take care and relax. You'll be fine.

Hope everyone else is well.

Cheers!