yikes- inr of 5.4 with use of nexium?

[Megan]

hey all.. so ive had two dental appointments in two weeks so 2 doses of amoxicillin - and i also started nexium and carafate for a possible ulcer in my throat. Last week I was at 3.9 and decreased doseage but it didnt help so now im holding off on warfarin 2 days to retest. my question is has anyone else taken nexium and had the same thing? ive read the posts and checked the drug interaction site and it says "postmarketing studies show possibility of increase in inr..." whatever that means..trying not to use any knives right now! and no bike riding or skiing.. thanks
im just a little worried. megan

 

[Ross]

WARFARIN SODIUM (in Coumadin Tablets) may interact with SUCRALFATE (in Carafate Tablets)

Sucralfate may decrease the absorption of warfarin from the stomach into the body. If this happens, then potentially less warfarin would be available for the body to use and blood levels could become too low. This could make warfarin less effective at preventing the formation of blood clots. If these drugs are used at the same time, sucralfate should not be taken within 2 hours before or after a dose of warfarin. Your doctor may want to monitor you closely for signs of a clotting disorder. Blood tests can be used to make sure that you are getting the right amount of warfarin. If you are experiencing problems, it may be necessary to adjust the dose of warfarin..You may want to ask your healthcare provider about this potential interaction if you think you are having problems.

This interaction is poorly documented and is considered minor in severity.

According to this, there is no interaction between Nexium and Coumadin, but the Carafate would slow the action of Coumadin down, meaning a lower INR. Something else is going on here.

From Nexium prescribing info pamphlet:

Warfarin
Concomitant administration of 40 mg NEXIUM (once daily for 3 weeks) to male and female patients on stable anticoagulation therapy with warfarin, resulted in a 13% increase in trough plasma levels of R-warfarin (the less potent enantiomer) while that of S-warfarin was unchanged. Coagulation times were stable throughout the entire study period. No clinically significant interaction was observed.

 

[catwoman]

http://www.valvereplacement.org/forums/showthread.php?t=28262

 

[jax]

I take nexium every day and have so for years now megan. It does nothing to my inr. However I've been on antibiotics since last tuesday and ate loads of vitamin K last week so my inr was fine but I am almost sure it is high this week as I have a bruise on my ankle for no apparent reason. Time for me to get the spinach out to try to help so I don't have to make a huge adjustments. Hopefully it helps a bit. I would say there is definitely something else besides the nexium and possibly it is the antibiotics you are on.

 

[ALCapshaw2]

hey all.. so ive had two dental appointments in two weeks so 2 doses of amoxicillin - and i also started nexium and carafate for a possible ulcer in my throat. Last week I was at 3.9 and decreased doseage but it didnt help so now im holding off on warfarin 2 days to retest. my question is has anyone else taken nexium and had the same thing? ive read the posts and checked the drug interaction site and it says "postmarketing studies show possibility of increase in inr..." whatever that means..trying not to use any knives right now! and no bike riding or skiing.. thanks
im just a little worried. megan

Holding your Warfarin for 2 Days is almost guaranteed to make your INR "Drop like a Rock".

Personally, I would cut ONE dose in half and retest in a week. That will move you in the right direction and get you into a 'safer' region and maybe even bring you back within your target range. If not, you can 'tweek' again to move back to where you need to be. I am a Big Believer in making SMALL Changes in dosing to bring INR back within range for moderately out of range INR results with NO Bleeding.

Another alternative would be to withold ONE dose and retest in a week.
Personally, I would NEVER hold 2 doses for an INR of 5.4 with NO Bleeding.

'AL C'

 

[Maryka]

Some medical people said I should take Nexium because my vocal cords had scar tissue (really from bad intubation during OHS, and required delicate throat surgery). I have heard bad things about longterm use of this class of drug (Nexium) and I refused to take it. I remembered that my father's solution to acid reflux was to line up several Tums at his bedside and would pop one each time he woke during the night. Now, I keep Tums by my bedside, just in case. Of course, you do not want to take a Tum close to the time you take your other meds because it will interfere with absorption of your other meds. I try to allow 1/2 to 1 hour before/after my other meds before taking a Tum. (OK, laugh, but it works!)

 

[catwoman]

I take nexium every day and have so for years now megan. It does nothing to my inr. However I've been on antibiotics since last tuesday and ate loads of vitamin K last week so my inr was fine but I am almost sure it is high this week as I have a bruise on my ankle for no apparent reason. Time for me to get the spinach out to try to help so I don't have to make a huge adjustments. Hopefully it helps a bit. I would say there is definitely something else besides the nexium and possibly it is the antibiotics you are on.

Jackie:
If you were taking Nexium before initiating warfarin, you wouldn't notice any change in INRs because your first INRs were already factoring in the Nexium. If you started taking Nexium (or some other proton pump inhibitor drug) after you began ACT with warfarin, you would notice a difference in INRs.
Antibiotics don't always affect INRs. Change in INR would depend on type of antibiotics and/or any concomitant factors (loss of appetite, dehydration, fever, etc.). I've taken a week's worth of amoxi (for a cat bite) w/out any effects on my INR. BTW, when I had my annual physical last week, I told my PCP about the cat bite I suffered on 7/4/2009 (I had posted elsewhere here about that). I still have slight nerve damage, but it's definitely much better.

 

[ALCapshaw2]

Some medical people said I should take Nexium because my vocal cords had scar tissue (really from bad intubation during OHS, and required delicate throat surgery). I have heard bad things about longterm use of this class of drug (Nexium) and I refused to take it. I remembered that my father's solution to acid reflux was to line up several Tums at his bedside and would pop one each time he woke during the night. Now, I keep Tums by my bedside, just in case. Of course, you do not want to take a Tum close to the time you take your other meds because it will interfere with absorption of your other meds. I try to allow 1/2 to 1 hour before/after my other meds before taking a Tum. (OK, laugh, but it works!)

What sorts of things "have you heard" about taking Proton Pump Inhibitors (the class of drugs that Nexium is)?
Did you ask a PHARMACIST or Physician about these "things you have heard"?
FWIW, I know people who have been on Prilosec for YEARS.

BTW, I hope you are aware that taking Antacids (such as TUMS) within 2 hours of when you take your Coumadin / Warfarin can reduce the absorption and therefore the effectiveness of the Coumadin / Warfarin. My Gastroenterologist recommends Nexium (or Prilosec which costs less) taken in the morning and Pepcid (also available as a generic drug) before going to bed).

You should discuss the side effects of ANY and ALL Drugs with your Anti-Coagulation Manager (and Pharmacist).

My recommendation: GET THE FACTS before you decide on a course of action.
Confirming the information through multiple sources is wise.

'AL Capshaw'

 

[Rich]

Megan,
I took Nexium for two and a half years.
It had a very dramatic impact on my INR. I had to reduce my dosage from 30mg/wk down to 22.5mg/wk. That is a big drop.
Although the Nexium certainly did it's job, my advice is to be careful with use of this drug.
Due to another problem I was experiencing several years ago, I suspected the Nexium.
I spoke directly to Astra-Zeneca, the makers of Nexium. They said their recommendation for patients was to only take this drug for four to eight weeks. They also told me the longest test they have done for side effects is twelve months. After that they could not say what else may occur after that time frame.
I don't take this lightly because I have lost several friends to throat cancer.
I would ask my doctor if I were you and see what he/she has to say.
Rich

 

[Rich]

In addition here is a list of possible long term side effecta for Nexium.

Body as a Whole: abdomen enlarged, allergic reaction, asthenia, back pain, chest pain, substernal chest pain, facial edema, peripheral edema, hot flushes, fatigue, fever, flu-like disorder, generalized edema, leg edema, malaise, pain, rigors; Cardiovascular: flushing, hypertension, tachycardia; Endocrine: goiter; Gastrointestinal: bowel irregularity, constipation aggravated, dyspepsia, dysphagia, dysplasia GI, epigastric pain, eructation, esophageal disorder, frequent stools, gastroenteritis, GI hemorrhage, GI symptoms not otherwise specified, hiccup, melena, mouth disorder, pharynx disorder, rectal disorder, serum gastrin increased, tongue disorder, tongue edema, ulcerative stomatitis, vomiting; Hearing: earache, tinnitus; Hematologic: anemia, anemia hypochromic, cervical lymphoadenopathy, epistaxis, leukocytosis, leukopenia, thrombocytopenia; Hepatic: bilirubinemia, hepatic function abnormal, SGOT increased, SGPT increased; Metabolic/Nutritional: glycosuria, hyperuricemia, hyponatremia, increased alkaline phosphatase, thirst, vitamin B12 deficiency, weight increase, weight decrease; Musculoskeletal: arthralgia, arthritis aggravated, arthropathy, cramps, fibromyalgia syndrome, hernia, polymyalgia rheumatica; Nervous System/Psychiatric: anorexia, apathy, appetite increased, confusion, depression aggravated, dizziness, hypertonia, nervousness, hypoesthesia, impotence, insomnia, migraine, migraine aggravated, paresthesia, sleep disorder, somnolence, tremor, vertigo, visual field defect; Reproductive: dysmenorrhea, menstrual disorder, vaginitis; Respiratory: asthma aggravated, coughing, dyspnea, larynx edema, pharyngitis, rhinitis, sinusitis; Skin and Appendages: acne, angioedema, dermatitis, pruritus, pruritus ani, rash, rash erythematous, rash maculo-papular, skin inflammation, sweating increased, urticaria; Special Senses: otitis media, parosmia, taste loss, taste perversion; Urogenital: abnormal urine, albuminuria, cystitis, dysuria, fungal infection, hematuria, micturition frequency, moniliasis, genital moniliasis, polyuria; Visual: conjunctivitis, vision abnormal.

Endoscopic findings that were reported as adverse reactions include: duodenitis, esophagitis, esophageal stricture, esophageal ulceration, esophageal varices, gastric ulcer, gastritis, hernia, benign polyps or nodules, Barrett's esophagus, and mucosal discoloration.

Rich

 

[olefin]

and i also started nexium and carafate for a possible ulcer in my throat.

I was taking carafate before and after AVR for a previous bleeding duodenal ulcer. Discontinued the carafate after couple years, had no change in INR.

 

[ALCapshaw2]

I was taking carafate before and after AVR for a previous bleeding duodenal ulcer. Discontinued the carafate after couple years, had no change in INR.

O.F. - I'd be interested in knowing if you saw any difference in INR when you Started and Stopped taking Carafate.

'AL C'

 

[Maryka]

Sorry I did not check here sooner. I had to get my car ready for periodic emissions testing yesterday, so was busy all day.

Al Capshaw: When my daughter was a college student, one of her young female friends was on Nexium or one of that class of drugs. Apparently her barely-out-of-her-teens friend had been on the drug since high school and had decided, after those many years, to get off of the drug. The young woman discovered that her ability to make a normal level of digestive juices had apparently been destroyed. I do not know what happened to my daughter's friend, but the lesson she learned scared me enough to be very cautious.

In my case, I do not think I truly have regurg very often, even though the doctors, eager to push their pills claim I must have it if I had scar tissue in my throat. (They totally disregarded that the scar tissue manifested shortly after OHS and intubation.) My throat has been clear for about a year now. I really do not take many Tums, day or night, but am NOT as afraid to take Tums as I would have been with the more "modern" drugs. Oh, and my father lived almost to 90 and did not die of anything related to his throat or to regurg.

 

[olefin]

O.F. - I'd be interested in knowing if you saw any difference in INR when you Started and Stopped taking Carafate.

'AL C'

I checked back on my old INR log and it never showed any more change than normal during the month I stopped Carafate. I say anymore change than normal, for my INR was usually not real constant. I had started taking Carafate the year before AVR. Couple years later went in to see my GI doc. He asked why I was taking Carafate? I answered, "because you prescribed it"! He then said I didn't need it for the ulcer had healed. The guy was really an excellent gastroenterologist. Later he prescribed Pantoprazole for ulcer prevention.

 

[Megan]

Thank you to everyone! I was thinking I should follow al's advice and not skip two doses but i had both my Dr and my nurse practitioner who does the testing all day both tell me to do that so I went with it- skipped the two doses and guess what? al was right- in two days the Inr DROPPED TO 1.8!!! Is that insane or what? i also stopped the carafate and nexium. the NP today said its common in young people-and im 40 as a refresher- to drop like this. and im sitting there thinking thank god for you people! should have gone with my gut and followed your advice! so now im going to go back on the nexium and carafate for two more weeks and monitor again in another two days. crazy. here is the spot i found online at rxlist.com about nexium. could be i just reacted strongly to it. could have been the combo of amoxicillin. no diet or exercise changes though so it has to be the nexium with me im guessing since the carafate would lower it. i also didnt know about the tums issue- i had been taking tums along with my warfarin before bed lately so will stop that practice asap. i love you guys- thanks so much for all the advice. i am so thankful.

 

[Megan]

From RXLIST.com: on nexium..

Effects on Hepatic Metabolism/Cytochrome P-450 Pathways
Esomeprazole is extensively metabolized in the liver by CYP 2C19 and CYP 3A4. In vitro and in vivo studies have shown that esomeprazole is not likely to inhibit CYPs 1A2, 2A6, 2C9, 2D6, 2E1, and 3A4. No clinically relevant interactions with drugs metabolized by these CYP enzymes would be expected. Drug interaction studies have shown that esomeprazole does not have any clinically significant interactions with phenytoin, warfarin, quinidine, clarithromycin, or amoxicillin.

However, post-marketing reports of changes in prothrombin measures have been received among patients on concomitant warfarin and esomeprazole therapy. Increases in INR and prothrombin time may lead to abnormal bleeding and even death. Patients treated with proton pump inhibitors and warfarin concomitantly may need to be monitored for increases in INR and prothrombin time

 

[Ross]

Thank you to everyone! I was thinking I should follow al's advice and not skip two doses but i had both my Dr and my nurse practitioner who does the testing all day both tell me to do that so I went with it- skipped the two doses and guess what? al was right- in two days the Inr DROPPED TO 1.8!!! Is that insane or what?

Hon there is a difference between those of us that take it, self test and self dose, and those that only dispense advice and are not on the drug. WE UNDERSTAND the drug much better then they do!

I would have told you to skip 1 dose and half the next. It's not insane to drop like that when skipping two doses. That is what happens to anyone.

 

[catwoman]

From RXLIST.com: on nexium..

Effects on Hepatic Metabolism/Cytochrome P-450 Pathways
Esomeprazole is extensively metabolized in the liver by CYP 2C19 and CYP 3A4. In vitro and in vivo studies have shown that esomeprazole is not likely to inhibit CYPs 1A2, 2A6, 2C9, 2D6, 2E1, and 3A4. No clinically relevant interactions with drugs metabolized by these CYP enzymes would be expected. Drug interaction studies have shown that esomeprazole does not have any clinically significant interactions with phenytoin, warfarin, quinidine, clarithromycin, or amoxicillin.

However, post-marketing reports of changes in prothrombin measures have been received among patients on concomitant warfarin and esomeprazole therapy. Increases in INR and prothrombin time may lead to abnormal bleeding and even death. Patients treated with proton pump inhibitors and warfarin concomitantly may need to be monitored for increases in INR and prothrombin time

Megan:
It's not just YOUNG people whose INR would change.
Anyone's INR would be subject to change when taking an Rx or OTC that affects the GI tract. About 50% of your vitamin K is produced in the GI tract. Disturbances there will probably cause INR increases because the vitamin K that would have balanced out your warfarin dosage is gone.

Perhaps your doctor's office needs to be informed of this. )))

Check out Page 15:

http://packageinserts.bms.com/pi/pi_coumadin.pdf

 

[Megan]

ok thanks KIDS! What about probiotics? anyone take those? you know the good live cultures found in yougurt? any effects known?!

 

[Rich]

Megan,
When I was having all kinds of problems several years ago, that's when I stopped the Nexium after two and a half years. I had to really monitor my blood level for a while. I had to go from 22.5mg/wk to 30mg/wk which I still take to this day. So be careful.
Then my GI doctor told me to take a probiotic called Align. I did for a few months and it really helped get 'things' moving again. I was also warned not to buy it at a local store but rather order it direct online. Apparently some stores charge twice as much then if you buy it online. It runs about $30 for a 30 day supply. However after further discussion he agreed that eating yogurt every day would probably work just as well, and it has for the better part of three years. Now I eat a small thingy of Activia each and every day and 'everything' works just fine.
I sure am not an expert but my theory is that the Nexium killed the bad bacteria causing the acid reflux, but I think it killed the good bacteria as well.
Good luck out there, I hope you can get this figured out.
Rich