What's to Low/to High??

[Mama2Rylan]

Ok, now I am getting very confused. I have been taking coumadin for about 3 months now, and my INR has been pretty consistant. My range is 2.5-3.5 but the last couple weeks my INR has been much lower. Three weeks ago, I went in to get it checked and it was 3.0 (perfect) then the week after that I went to get it checked and the first fingerstick was 1.9. So I asked her to do it again and the second one was 1.3 So of course I was very worried, so they did a blood draw and came to the conclusion that my INR was 1.7 Now, to me that still sounds pretty low. At what point do they decide to use heprin injections?
I was also wondering at what point does your dosage actually go into effect. Like when I take my coumadin on Monday, when does that dosage actually effect my INR. I was told it takes a couple days, so I was wondering when they increased my coumadin, when will that start to help?
One more question, if you miss a dose, how long does it take to effect the INR?
Sorry for all the question, I thought I was getting all of this stuff but then now I'm just not sure Thanks guys for the help!

 

[geebee]

Your INR is definitely too low. It usually takes about 3 days for an increase to show up in your INR but everyone is a little different. Since your INR seems to have been low for a couple of weeks now, I would talk to your doctor and get some advice. I hope your coumadin has been increased.

Has there been any changes in your diet or exercise patterns in the last 3 weeks that could account for the lower INR? I believe exercise can cause a decrease in INR as well as a lot of additional Vit. K foods.

You are right to be worried so talk to your doctor and express your concern and interest in getting this fixed ASAP.

 

[ALCapshaw2]

The risk of CLOT formation begins to go up when INR goes BELOW 2.0 Worst Case: Clots MAY lead to Stroke of Pulmonary Embolism.

The risk of major BLEEDING begins to go up when INR goes ABOVE 5.0 Many think of the range from 3.5 to 5.0 as a "safety net" where it is still safe to go but INR needs to be gradually lowered to increase your margin of safety. This 'safety net' concept is why many prefer to be on the high side of the recommended range, giving them some 'safety' on BOTH sides of their normal level.

Regarding metabolization of Coumadin, it generally takes 3 to 4 days to be FULLY metabolized. It would seem to me that this is a GRADUAL process that is finally completed after 3 or 4 days rather than nothing happening until the third day and then kicking in FULL strength. That latter concept seems to be a popular but misleading conception.

Note to AL Lodwick: Can you confirm or clarify the above paragraph?

'AL Capshaw'

 

[Karlynn]

As the others have said, below 2 is too low. I missed taking all of my dose one day, then 3 days later tested a 1.4 and 1.7. I take a fairly large dose, so my INR drops fast if one is missed (or a partial one is missed )

I freaked out a bit but that being said, try not to freak out. I have been that low before many times in 14 years with no complications so far. Just because you are that low, doesn't mean you are guaranteed a stroke or TIA, it just means your chances are greater.

I had my valve when PT (protime) was the test used, not INR, andit was much more variable. I'm pretty sure my blood wasn't as anticoagulated back then as it is now.

Yes, speak to your doc. I'd test again in a 4days to a week after your dosage change has had a chance to register fully.

 

[geebee]

I don't want to hijack this thread but is the PT that shows up on our home testers (along with the INR) the same levels that we used for testing before INR was used?

If that's the case, I would have been below 2.0 INR for a long time.

 

[Mama2Rylan]

I don't know what caused the sudden drop in my INR, that is the main reason I was worring. Since I had my surgery just a couple months ago, I am very new to coumadin. No one really went over all the things to be careful for, or what would effect my INR. They just talked about all the "green" things...well I have tried to stay away from anything green. I was gonna start introducing those things back into my diet slowly but now I am nervous to do that. I haven't been exercising any more or less then usual. The only thing I can say that I really did differently was have three alcoholic beverages. But I was under the impression that was suppose to INCREASE your INR??

When I went in to get tested and found out about the sudden drop, my doctor didn't really seem to be worried I guess. I didn't actually talk to my doctor, just her nurse. All they did was increase my weekly coumadin dosage by 2.5MG so I don't know just how much that is going to help. I am going to see my cardiologist next week, and she is going to check my INR so hopefully this can all get worked out.

(Ps. I am also going to start the process of getting a home testing kit, easier to keep on top of these things, and it will make me feel so much better to test every week

 

[Ross]

You aren't sucking down carnation instant breakfasts, ensure or something like that are you? Mega Vit k in those and nutrion bars.

 

[Karlynn]

Your dose of Coumadin may continue to need to be adjusted upwards as you get farther along in your recovery and your body's organs get back to normal.

Just eat what you want and be conisistant.

How often are you testing?

 

[Guest]

There are four phases that a drug goes through in the body.
Absorption - getting into the blood stream
Distribution - getting to the site where it works
Metabolism - the drug is broken down by (usually) the liver
Elimination - expelled from the body

Warfarin is slow acting because it does nothing to the clotting factors already in the body. It slows the production of new factors.

Metabolism is by the liver and varies greatly by the particular set of enzymes that you inherited. The effect of warfarin seems to wear off in 1 to 4 days but this has more to do with the body producing new clotting factors rather than the actual metabolism of the drug. The INR does not measure the blood level of the drug, it measures the slowing of the clotting factors.


You should not count on alcohol to do anything to your INR. The effects are erratic at best or worst.

Avoiding greens is utter nonsense. When you start to add them back to your diet, they can throw everything off again.

The PT depends on the sensitivity of the materials used in the testing. You cannot draw any valid conclusions from the PT without knowing the sensitivity of the materials in the test - hence the INR.

It is unlikely that a low INR with a mechanical valve will lead to a pulmonary embolism. The worst case is paralyzing stroke. A pumlonary embolism usually comes from a blood clot in the leg. It has to do with where the blood vessels in the body go.

 

[ALCapshaw2]

I'm still confused Al (Lodwick).

When you say the Liver metabolizes Coumadin,
What exactly does that mean?

Is that when it becomes fully effective
or when it becomes no longer effective.

Also, is the metabolism of Coumadin
a continuous process spread over 3 to 4 days,
or does NOTHING happen until 3 or 4 days
after taking a particular dose.

'AL Capshaw'

 

[Natanni]

Stablizing INRO

Stablizing INRO

Mama2Rylan- My husband is still figuring out his INR as well, and has been hovering more so below the 2.5 marker as well. Just this week they upped his weekly dose by 2.5 so he will be on a steady 5 mg for now. He has been consistant, but on the low end. He did end up back down at a 1.9 when in the ER 2+wks ago with Afib, but he felt like crap so we attribute some to that. His PCP came in to see him and when Nathan said he wanted to go home and not stay in the hospital, his doc told him "Go home, have a beer and relax...but just one" He has not had one yet, but he is anxiously awaiting that "one beer" He has been doing green stuff like crazy. Not huge portions, but something every day. This weekend it was coleslaw, pretty big portions too. I was thinking maybe he should slow down on that some...two biggies with cabbabe and mayo....

I always thought that the allowed "drink or two" would up the INR level as well. Al-can we expect that beer to cause a change in either direction? Too bad it didn't balance out--Have a big salad and two glasses of wine and the INR stays the same

 

[Guest]

The best I can come up with is that I have never seen a problem with two drinks.

There can never be balance between warfarin, salad and alcohol because they all have different onset and offset of action. Moderation is the key.

I have one patient who has a big party for every Broncos game and drinks heavily. Every Tuesday she has rectal bleeding. Harley-Davidson thinks they have the world's greatest logo because people will tattoo it on their butts - but this has to rank right up (down) there.

 

[Diesel]

Hey Mama2Rylan:!!!!

I'm sorry to hear that you are having trouble with your coumadin levels. Want to hear a crazy thing.. I AM TOO! man it's been frustraiting. My level has been ranging roughly around 1.4ish.. I too have been stable since my surgery. They only think I did notice is that during my "cycle" week well my INR levels always drop. Last week was my "cycle" week (sorry if too much info!!!) and sure enough I dropped! But still today, Monday my level hasnt come back up. Last week my cardio upped my dose's and havent seen any real changes.. SO tonight where i am still low.. he uped my dose to a 10mg. and i have to retest on Thursday.

i've also been wondering if they will make me start on Heparin shots. The last time i was in the hospital (about 3 weeks ago) my INR level dropped too. I was put on heparin until my level reached 2.6 Which was still low, but close enought that i could get it back up. SOO Now that i am below what i was, im unsure why i am not on heparin?????

Hopefully we are both seeing they better side of this coumadin problems SOON!
Diesel

 

[ALCapshaw2]

There are four phases that a drug goes through in the body.
Absorption - getting into the blood stream
Distribution - getting to the site where it works
Metabolism - the drug is broken down by (usually) the liver
Elimination - expelled from the body

Warfarin is slow acting because it does nothing to the clotting factors already in the body. It slows the production of new factors.

Metabolism is by the liver and varies greatly by the particular set of enzymes that you inherited. The effect of warfarin seems to wear off in 1 to 4 days but this has more to do with the body producing new clotting factors rather than the actual metabolism of the drug. The INR does not measure the blood level of the drug, it measures the slowing of the clotting factors.


You should not count on alcohol to do anything to your INR. The effects are erratic at best or worst.

Avoiding greens is utter nonsense. When you start to add them back to your diet, they can throw everything off again.

The PT depends on the sensitivity of the materials used in the testing. You cannot draw any valid conclusions from the PT without knowing the sensitivity of the materials in the test - hence the INR.

It is unlikely that a low INR with a mechanical valve will lead to a pulmonary embolism. The worst case is paralyzing stroke. A pumlonary embolism usually comes from a blood clot in the leg. It has to do with where the blood vessels in the body go.

I'm still confused Al (Lodwick).

When you say the Liver metabolizes Coumadin,
What exactly does that mean?

Is that when it becomes fully effective
or when it becomes no longer effective.

Also, is the metabolism of Coumadin
a continuous process spread over 3 to 4 days,
or does NOTHING happen until 3 or 4 days
after taking a particular dose.

'AL Capshaw'

(YES, this is repeat of my previous post,
in hopes that AL Lodwick will see this one.
Sorry for the duplication.)

 

[TomS]

Eleven weeks post op my INR moved down to 1.9. The reason given was that I was back to full speed and was metabilizing the Coumadin quicker than before. Makes sense to me. We upped it and it's back in range.

Also, being new to this, I still don't understand the effect of alcohol. Is anyone aware of any actual tests out there that show what happens to INR and at what point? It seems like even in this forum there are wildly different opinions out there.

 

[catwoman]

Tom:

Bristol-Myers Squibb Company's leaflet on Coumadin that my PCP's office gave me lists alcohol giving both increased and decreased PT/INR results.

So, what it does to one person may not hold for the next person -- or maybe even the next situation. Al Lodwick may know something about the latter part of my last sentence.

The problem that alcohol poses is irritation to the GI tract, the potential for bleeding. Warfarin users would be apt to bleed more than other people. Folks with gastric erosion would really suffer, at least from pain if not from bleeding.

I love margaritas, martinis and white zinfandel. Have only noticed a high INR once after drinking 2 martinis in 1 weekend, but I can't be sure it was only the alcohol that was to blame.

 

[TomS]

Thanks Marsha. Given my first post-op holiday season approaching, I'm trying to figure this alcohol question out. We're also heading into the ski season, and when my buddies and their families get together dinners out is a big part of the experience. I can be looking at a couple of beers apres ski, a couple of glasses of wine at dinner, etc. Based on what I've read on this forum I can anticipate three outcomes from continuing this behavior.
1. My INR will more than likely go way out of tilt, particularly if I followed this for a few days. I can expect that I will be increasing my chance of stroke due to it being too low, or increasing my chances of complications should I injury myself skiing because it may be too high.
2. It's no big deal as long as I stay away from a three martini lunch, I can go ahead and enjoy myself.
3. Alcohol may have some effect on INR, but no one really knows what it might be.

 

[Guest]

Metabolizes means that the body changes it into something other than warfarin and it gets eliminated from the body. It is no longer effective when it is metabolized. Metabolism starts the next heart beat after it is absorbed.

The best you can conclude about the effect of alcohol is that it is erratic.

 

[Cris N]

Based on what I've read on this forum I can anticipate three outcomes from continuing this behavior.
1. My INR will more than likely go way out of tilt, particularly if I followed this for a few days. I can expect that I will be increasing my chance of stroke due to it being too low, or increasing my chances of complications should I injury myself skiing because it may be too high.
2. It's no big deal as long as I stay away from a three martini lunch, I can go ahead and enjoy myself.
3. Alcohol may have some effect on INR, but no one really knows what it might be.

Pretty much sums it up I'd say.