Zetia X 2 weeks, INR slowly climbing

[Natanni]

Okay, Nathan's doc wants him to home test twice a week while his body adapts to the Zetia, and the first week there was no change in his INR. Week #2 his INR had rose from 2.8 (where it has hovered since 12/05) to 3.2 (Wednesday). So he kicked up the salad in take and started and also added greens in his sandwiches at work etc etc. This morning he is 4.0; He does not want to adjust his coumadin at this time. He has a name, "micromanaging" his coumadin, and last time he messed with his dose, things got all screwed up. Now, he also didn't have but one glass of wine in the last week (he was drinking maybe 3 a week, with a beer or two on the w/e...I know....asking for screw ups, but I am being honest...but before he was quite consistant with his alcohol intake) OKAY....so instead today I bought spinich to add to his salads and thought we would try and get it lower this way. Question is, does the timing sound about right for the Zetia to be affecting his INR 2nd week out? I thought it made sense that it would be more slow acting, rather than a faster response. Would you guys leave your dosing alone at 4.0?

Thanks much as always

 

[Karlynn]

If my INR was climbing steadily and I was on a drug that was known to raise the INR, I would adjust the dose for a 4.0 reading. With the way my body reacts to a dose adjustment, I would probably only do a 5% for me then test in 4 days to see if the INR is still climbing.

By keeping the same dose and adjusting his diet, he is falling in to the "dieting the dose, instead of dosing the diet" routine. This is the harder path to take and much less successful in the long-run, IMHO. If he's leaving out his beer and wine (which sounds moderate and reasonable - IMDCRO - In My Diet Coke and Rum Opinion ) he's starting to eliminate small pleasures he doesn't have to, if he doesn't want to. If he's making permanent changes in diet for other medical reasons, that's one issue, if he's doing it just in order to not have to adjust his warfarin dose, that's taking the hard road.

 

[Guest]

"Testing twice a week until ..." The surest way to guarantee that the INR will be out of range.

 

[Ross]

I was going to say that 2.8 and 3.2 is insignificant, but looks like y'all are on the ball and I'm not.

 

[Natanni]

Thank you all so much for your input!

Karlynn--he didn't want to eliminate the wine or beer, it was more a factor of getting stuck at our daughter's skating arena all week for practice Hoping to incorporate it back into the program this week.

Okay, I am slightly more confused; Testing twice a week is a guarantee to get out of range? HELP! I don't get it. I was so darn excited his GP encouages home monitoring too.....isn't it better to find out sooner to see if this med is affecting your INR? I mean, I understand that coumadin takes many days to metabolize, but one doesn't know how one's body is going to react to this new med, could be metabolized quicker? Wouldn't a person want to know if they hit 5.5 before they hit 7.0???? I thought this was one of the advantages of home monitoring.....I am confused!!

 

[Guest]

Warfarin dose changes take 3 to 5 days to show up on the INR (usually). Testing more than once per week usually results in dose changes being made before the effects of the last dose change shows up. Thus it will be only random chance if the INR is in range - no science behind it. The only way around it is to base the dose change on the previous 7 days total warfarin dose. But if you are going to do that, why bother to test so often? This is esp[ecially true when there is no known interaction between Zetia and warfarin. It is very unlikely that any dose out of range for less than one week will result in a serious problem. The only time that I would test more than once weekly is if the INR was already at 8 and I had them hold for two days.

 

[Natanni]

Thank you for taking time to explain this Al, and I am so sorry if I am still coming off as being confused, I am still trying to understand this;

Warfarin doses take 3 to 5 days to show up in INR...okay, but what if you are not changing the dosing, and you are testing only to track the new medications response on the INR, which is climbing. When Nathan was contemplating which valve tissue/mechanical, we were told that having your INR in your target range reduces your risk of a clot/bleeding event; I have not really checked into Zetia's affect on INR myself, I am only going on what his doc felt; He felt that Zetia had the least effect on INR in comparison to the other cholesterol reducing medications like Lipitor, Crestor, ?Pravachol was brought up I think. But he said that because it is a newer mediction and he said it may still play with his INR he wanted him to test biweekly. Now I wish Nathan would not have skipped those darn few beers because that is the only other change he has made and his INR continues to climb. My thinking is that if Nathan waits and does not change his dosage and waited a week before testing again, he would be 6.2 if he kept climbing as he is doing now. Wouldn't it be safer to test Wednesday to find his INR at 5.2 and alter his dose sooner rather than have it get that far away from us?

 

[Guest]

Hey, I've been doing it for 8+ years full-time and I'm still learning.

 

[Karlynn]

Anni, if I test more than once a week it's to make sure my INR is heading in the direction my dosage change is intending it to head not to see if it's in range at that time. I don't do so assuming I'm going to make a change, and I wouldn't make a change unless my dose change for the week appears to be wildly off track from what I intended it to do. This has not happened. I rarely test more than once a week for an INR that is 4. And if I have an INR of 4 I rarely make a change - unless, in a case like your husband's, I'm taking a medication that is known to raise the INR.

I should also add that I have 14 years under my belt, of seeing how changes in my Coumadin will be received by my body. In Nate's case, you're new to this, so dose changing more than once a week will most likely end up giving Nate the moniker of "hard to stabilize", particularly if the doctor is making 5 - 10% changes each time. Al is, of course, right, the weekly INR is your best look at what a dose change did.

Moderate consumption of alcohol doesn't seem to do much to my INR. I'll go for a few weeks where I'll have a rum and diet coke 3 or 4 times that week. Then I'll go for a few weeks where I just don't, for whatever reason. My INR doesn't reflect any change, or much of a change for that inconsistancy.

 

[Ross]

People place to much value on what they drink and eat. Those few beers missed won't amount to anything, so don't worry about them.

 

[Natanni]

Thank you Al, Karlynn and Ross.... so much for your patience on this. You guys are saving Nathan alot of stress. I am a nurse, and yet I feel so inept at times, and that makes me feel all the more frustrated Better I come here and have my panic and then I can make like all normal to him...hehehe...I am going overboard on 'prevention' issues, in all aspects. You should see all the armor I want Nathan to put on before he snowmobiles. I would send him to work this way as well....

Okay, Nathan has not altered his dose at all yet at 4.0; He wants to ride it out and see what it does. This is okay then?

 

[Ross]

I think that is what all of us would do. If after 7 days it's still rising, then maybe make a small adjustment, but as Al pointed out, no interaction between the drugs have been recorded, so it shouldn't be rising.