What's up with my INR?

[Raverlaw]

Being new to this whole Coumadin thing, I'm just waiting around to get stabilized. I had surgery the 20th, and I think they gave me Coumadin 5 mg starting Saturday the 21st; I had it every day in the hospital plus injections of Heparin on Saturday, Sunday and Monday. By Tuesday the 24th, my INR was 1.7, but they sent me home with instructions to continue 5 mg daily plus an 81 mg aspirin. On Thursday the 26th, my first PT test showed an INR of 1.7, so they upped me to 7.5 mg of Coumadin, which I took on Thursday, Friday, Saturday and Sunday. Second PT test was Monday, and my INR was 6.6!! So they told me NOT to take any Coumadin Monday night, and to skip my aspirin Tuesday morning. I went for another PT test today, (Tuesday) and am waiting for the results.

My diet has been consistent while I've been home. I eat a small salad every day, and have been walking twice a day. I had my first post-op glass of wine Sunday night, 1 oz. and another Monday night.

Is it normal to vary this wildly while trying to get stabilized?

 

[Ross]

At first, yes it's the pits getting regulated. I'm sure by the time I type this, you'll have seen my other post to you in your other thread. I do not give credit to veinous lab results. There are too many factors that come into play to get the results. See if you can get to a fingerstick clinic or see if you can get your own monitor.

 

[Nancy]

Well, obviously they overshot your dosage when they upped it for the four day period. It was probably on its way up. I think if they had waited to test you until Friday the 27th, it would have showed movement from the 1.7, and the adjustment would have been less. There is a 3 day lag in the time you get your adjustment and the time the new dosage shows up in your test. They had you test in 2 days instead of 3, and that's what probably caused the "overshot".

It is tricky at first getting things to a manageable level.

But Coumadin is always tricky. You have to have someone monitoring you that understands the idiosyncrasies of Coumadin. If you have someone like that, then it's not so difficult.

 

[RobThatsMe]

Hi Bill,

Yup... after surgery they have a time regulating you. Not sure what to start you at, so they test you every 3 days for a few weeks. Then once they think they got it,, you become more active as you feel better,,, there it goes again,,,, then you are weaned off some of your meds..and that causes more fluctuation.

Eventually it will smooth out.. be patient.. and don't wait too long to get your results from your labs. The sooner you get them, the quicker you can take action. You don't want it getting too outta control, above 2 and below 4 is good.

Hope this helps some, I used to panic over my INR being off even a few decimals... that was nuts..Now I rarely am concerned as long as it is between 2 and 4.

Wishing you a speedy recovery,

Rob

 

[Johnny Stephens]

Being new to this whole Coumadin thing, I'm just waiting around to get stabilized.

As the others have said, this takes some time. Surgery was only a couple of weeks ago, right? This will likely take a couple more at least, and will also continue to creep around as your appetite and exercise capacity increase.

Be patient -

 

[medtronic of borg]

food for thought

food for thought

I think I'd skip the alchohol untill the Dr. has you regulated.

Med

 

[Marge]

Bill, if it's any consolation, I'm a week or so ahead of you in timing of my surgery and they haven't got my INR stabilized either. I got out of the hospital on 2/17, at 1.5. On 2/19, at my first blood draw, my INR was 1.8. They've been tinkering with my dosage ever since. INR went down, from 1.8 to 1.1., and then (yesterday) up again, but only to 1.4. So they've adjusted the dosage yet again and I go in for another blood draw on Thursday. I've been going to the lab every Thursday and every Monday since discharge & it is getting to be a bit of a nuisance. The lab people don't even like to see me coming in anymore, I've run out of easy places for them to get blood from. My coverage is through Kaiser, so I don't have the option of switching labs or techniques (except I could go to another lab within the Kaiser system). If I had to be doing this for the rest of my life, like you, I'd eventually see about getting a home monitor. But I'm only on this warfarin stuff for three months.

I've been reasonably (I think) consistent in diet and exercise. I haven't had any alcohol. I wonder if they'll have it straightened out by the time I'm ready to go off it.

 

[Rich]

Hi Bill,
It will get better but it does take some time.
Mine has been really stable for seven and a half years.
But lately over the last few months it has taken a nose dive.
It's because of increased activity as was mentioned so now i'm bouncing up and down.
It just proves that you can never be perfect with this stuff but oveall it hasn't been a big deal.
I'm sure over time you will recognize the things that can affect it.

Ross,
What is the problem with getting a vein draw vs. a finger poke.
The lab at my hospital only does a vein draw and that vein in my arm sure looks like it after 100 plus pokes.

Rich

 

[tommy]

Bill,

Your system may be very sensitive. Mine is. A change of 2.5 mg in a week makes a dramatic change in my INR. Couple that with the normal hypersensitivity post surgery, and you are on a roller coaster.

The added challenge is......what dose do you take while you are waiting for the lab results? Finger stick results are available immediately.

Glad you mentioned the glass of wine. Probably a good idea to hold off on alcohol for a while longer. Long term strategy is: do what you want and adjust the dose - just be consistent, especially within three days of a test.. In the short term, reduce the variables until you get the INR stable. My doc said no alcohol for a month. Check with yours.

You are still doing great.

 

[Raverlaw]

Thanks, everyone.

My lab gets the results back same day, and I take my warfarin in the evening, so I can adjust the dose right away.

Today's test said the INR was down to 4.4, so the doctor told me to skip again tonight and resume tomorrow at 5 mg. He also said to stay off the aspirin for the time being.

My thought on the alcohol was to do what I am going to do and let them adjust the dose to fit. I only had 1 oz. (Sandy even measured it) on Sunday and Monday night, but we had hot dogs tonight, so I skipped. The only thing I drink with any regularity is red wine, and never more than 2-3 oz. per evening.

I'll talk it over with the Doc tomorrow when they take the staples out. They want me to test again Thursday, which I think is too soon. I'd rather wait until Monday and see what's cookin'.

The input from you experienced "users" has been very valuable. Thanks.

 

[Ross]

I don't want you to think I was barking at you in the other thread. If you take your dose in the evening, they should wait until Monday to test you. If they test you Thursday, that dose you took on Wednesday will not even show up. If your clinic holds true like so many others do, they'll start trying to adjust while your not even registering the proper level. Hence, no regulation.

Honestly Bill, there are so many places that claim to be Coumadin Clinics, but the people working them have no clue how to manage Coumadin.

I'm no self professional, but after having my arm jabbed way more then necessary, I feel a special need to yell about these things.

 

[Ross]

Here is a link and a .pdf file for you to download. I think these will help you tremendously in understanding how this drug works and why I think your Coumadin Clinician may not know how to manage it properly. Again, just trying to educate the unknowing, not pound information into people.

http://www.aafp.org/afp/990201ap/635.html

 

[Raverlaw]

Ross,

Thanks for the .pdf. I printed it out and will read it.

I don't have a "clinician" yet - I'm still under the surgeon's care and all of this info is being relayed through his nurse. I'll get to speak with him tomorrow afternoon, and I'm going to tell him that I think they're monitoring too closely and adjusting before the effects of the last adjustment can be seen.

When I get released, it will be to my PCP, who, as it fortunately turns out, is THE coumadin clinician hereabouts. I can't wait.

 

[Ross]

If you need to take some of that documentation with you, please do. I'm trying to save your veins, God knows those people sure like to stick them as many times as possible and sometimes, unnecessarily. Money for them, pain and scar tissue for you.

 

[ALCapshaw2]

Bill,

I would also be concerned about their HOLD instructions.

INR can PLUMMET when held but takes time to rise when increased. You'll get the hang of it after a while.

The technique I prefer is if your INR is LOW, increase the WEEKLY Dose by 10 to 15%, spread over 7 days.

If your INR is HIGH, reduce the WEEKLY Dose by 10 to 15% spread over 7 days.

Retest after 3 or 4 days.

You may want to ckeck with Al Lodwick, our resident Pharmacist and Coumadin Clinic Director.

'AL'

 

[ALCapshaw2]

Perhaps I should have also said if your INR is REALLY HIGH, then cut your dose in half for one or two days. You really need to get a recommendation from your Coumadin Clinic on this. I just don't like the idea of holding doses, especially for more than one day. It really 'pings' the system response and usually takes longer to 'settle down'.

The technique I use for missed doses was recommended by someone here on the Coumadin Forum and that is to divide the missed dose by 3, and add that amount to your daily dose over the next 3 days. By the end of the week, you will be back to your normal weekly level without 'shocking' your system (i.e. never double a dose in one day).

'AL'

 

[EVELYN]

Hi Bill

Yes, I can remember well Tyce's trouble post op getting his coumadin right. Even now we sometimes have trouble. We do follow the 10-15% rule and VERY rarely withhold any dose because he has a tendency to crash low. We will halve the dose if he's super high and the cardio says to withhold, though.

I have come to believe that INR does mean, "IT'S NEVER RIGHT!!" We do also home test, and hopefully will be receiving a Coaguchek unit as our Protime just didn't seem to work with Tyce's chemistry....too great a variance between our cardio's coagucheks and hospital lab drawn.

Listen to both Als....We have relaxed quite a bit and are now "happier" to be higher than lower. I truly think it's a matter of time till you adust.

Tyce has a glass of wine every night and it works right in to his INR.....no problem. It's much better to be consistent than to have nothing and then go wild.

It will work out for you.

 

[Raverlaw]

Update

Update

Well, today (Thursday) I got tested again, and the INR was 2.8; first time I've been in range since I started.

This is after two days of NO warfarin at all, so I'm worried that my INR is heading down out of range again. The doctor's instructions were to take 2.5 mg tonight and stay on that through Sunday, get tested again on Monday. Oh, and they want me back on the baby aspirin, too.

So I took the 2.5 mg tonight and had 1.5 oz of red wine with dinner. We'll see what next week brings!

 

[Ross]

This should be very interesting. This I gotta see.

 

[Raverlaw]

Ok Ross,

Here's the deal. I'm going to take the warfarin as instructed, 2.5 mg daily through Sunday, with aspirin.

Who wants in on a pool to guess my INR Monday? A dollar a throw, everything to the winner?