Pain Killers with Coumadin

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Don't just depend on a person's title to decide whether they know what they are doing (ie cardiologist vs PCP). I've had cardiologists tell me that they want nothing to do with warfarin. That it should be managed by the PCP.
"I didn't do all this schooling and specialty training to wind up dosing Coumadin. That is the primary doc's job."
 
Who manages warfarin?

Who manages warfarin?

I have found that many of my fellow MD's have little knowledge and even less interest in managing warfarin.
This includes PCP's, cardiologists, heart surgeons.etc. They often leave it up to their office nurse or lab tech which can be OK or not so good. At Kaiser where I now practise, the pharmacists, like Al ,run the program and do it very well.
 
The reason we get good at it is that we do so many. Monitoring warfarin is all that I have done for the past 4.5 years. I have seen about 12,000 patient visits. If a physician saw two patients on warfarin a day for 250 days per year they would have to have 25 years experience to have seen as many warfarin patients as I have. If I was not doing a good job, then the doctors would soon quit sending patients to me and I'd be back working rotating shifts.
 
Hi Al

If you don't mind me asking....what is your usual protocol when a patient has an out of range higher end INR, say 4.5+?

Thank you
 
This is why I don't like computer programs for dosing, I try to treat each case on an individual basis. I had the statistician at out medical center look at over 2,500 patient visits. We broke the INRs down into three categories. Group 1 was INRs of 1.0 to 3.5. (Everybody in, or below a therapeutic range recommeded by the Chest Physicians guidelines). The next group was 3.6 to 5.0 (slightly elevated and below where the Chest Physicians recommends giving any treatment). The last group was all INRs above 5.0. At every visit I ask people if they had any bleeding problems. Almost every problem was a bloody nose. Group 1 and Group 2. reported bloody noses at the same rate. Group 3 reported bloody noses at a higher rate. So we concluded that people who have an INR of 5.0 or less and who get their INR checked about monthly had no higher risk of bleeding than if their INR was at any number less than 5.0. (I presented this at the Anticoagulation Forum meeting in Washington DC in May 2001 and it was published in the journal Thrombosis and Thrombolysis.)

With this background, I'll get to the answer to your question. If the person has been taking a steady dose of warfarin and keeping their INR in ranges for six months or so and then suddenly has an INR of 4 to 5, and reports no problem, I'll try to find out why. But, in the majority of cases, you cannot find an answer. (I suspect that taking an extra dose because people forget they already took one is fairly common.) So in this case I will have them hold one warfarin dose and resume the same dose and check them again in about 4 weeks. If it is still elevated in four weeks, and there is still no problem, I'll do one of two things, either the same thing that I did the month before or I'll reduce their warfarin dose by the equivalent on one day's dose of warfarin per week. (If they are taking 5 mg/day [35 mg/wk] reduce it by 5 mg to 30 mg/wk.) Only 7.6% of people reported minor bleeding in this group, so it is hard for me to get excited about an INR of 4.5

I also reported in my study that we live at 4,700 feet elevation in one of the driest places in the United States. We receive less than 12 inches of moisture per year (often 4 inches will come in less than one hour) and the humidity is often less than 10%. This causes a lot of cracking of the nasal passages.

One other thing that has to be considered is the reason for taking warfarin. If someone has lupus anticoagulant, the INR reading is often falsely elevated. I have two women patients with this. If their INR ever drops below 2.0 they are in the hospital with blood clots in their legs, sometimes going to their lungs. They are both quite happy to keep their INR in the 4 to 5 range. They will trade a bloody nose for a clot any day of the week.

So the answer is that I do not have a protocol. I try to treat each person as an individual. I also give them my reasoning for the decision. If they disagree, we try to reach a compromise.
 
Hi Al,

Hi Al,

It sure sounds like you do a terrific job for your patients and are very knowledgeable.

My Cardiologist does monitor mine, and I'm thankful that he does. To my knowledge we don't have anyone like you in my area that has the expertise, so prefer my Cardiologist to my PCP for monitoring.

Thanks for all the great info you are giving us!!!

Zipper *~*
 
Thank you Al for you response. Wish there were more individuals out there like you. As we know... Coumadin is very individualized.

My cardiologist still can't believe that when holding one day.... I hit rock bottom.

What works for me is cutting my dose in half for one day with reading 4.0 - 5.5. Resuming my regular dose if I was within range for my last few tests. If not, decrease 10% for the next week. 5.5 - 6.5, subtract 4 mg from my daily intake. Anything higher than that and I would be calling it in.
 
Gina, didn't you say that you take 20 mg/day. That is another individual thing that I did not mention. If you take more than about 10 mg/day, you are a rapid metabolizer of warfarin. That is why you need such a big dose. Usually the INR will decline by about half over 48 hours. But anyone who takes more than about 10 mg/day will probably metabolize warfarin rapidly enough that it will only take about 24 hours to clear it from the body. The largest dose of warfarin ever reported was 660 mg/day. That is correct 66 of the 10 mg tablets daily!!! There is a guy in this area, not my patient, who takes over 100 mg daily. The biggest reported at my clinic is 25 mg/day, but I kind of don't believe that he takes it every day. He is a cowboy who has hepatitis C, so I think he takes some other stuff out there with the livestock, and I not referring to locoweed. Around here locoweed is Datura stramonium not Cannabis sativa!!

Zipper, If you want to know if there is a clinic similar to mine in your area, look at our professional organization's website www.acforum.org and click on clinic locations.
 
Hi Al

I am a straight 6-1/2 mg a day. At times 6mg straight.
Recall reading....over 5mg a day would be considered fast matabolizer, correct?

Can add greens by upping 1mg-2mg for the week. Iceburg Lettuce Salad, occasional asparagus and broccoli. By this, I am able to enjoy these veggies 3-4 times weekly.
 
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Hi Al and Gina,

Hi Al and Gina,

Thanks Al, I did check that site and found several clinics here in the Bay Area in California. Since they are Stanford, Kaiser, Veterans, and S.M Co. General they are not ones I could use.

Since I work for a hospital and am insured through them..I must stay with 'the program' in order to be covered. I work for CHW..it's connected with the San Francisco Heart Institute as is my cardiologist and surgeon. I do thank you so much, tho for the information.

For both you and Gina...As she referred to changing dosage in order to eat some 'greens', it brought another question to mind. I dearly miss my salads, and the only time I indulge is when dining out or having company in. At these times, I normally will have wine with dinner. I have not experienced any change in INR at these times....Does this indicate, in any way, that the wine may offset the greens ??? I do not intend to encourage consumption of wine at all...it just brought up a question in my mind. I also will state that this an infrequent occurance and therefore could very well be why no change occurs. Hmmm..just curious...

Thanks again,

Zipper *~*
 
I doubt that one salad and one glass of wine would have any significant effect on the INR.

I tell my patients that there is no need to avoid green vegetables. I have they eat what they like and adjust the warfarin dose around it. I think that most people eat about the same amount of vegetables over the course of a week. Since I dose warfarin on a weekly basis, I don't find that there is anything significant happening. What I do say is that if you go out to dinner and really pig out on the salad bar, then eat corn, cauliflower or something else low in vitamin K the next day and it will all iron out.

Remember that the INR guidelines are just that, guidelines. They are not absolutes. It does not mean that if you stray out of the line by 0.1 units for one hour that you will have a clot.
 
Salads/dosage

Salads/dosage

The reason I try not to eat too many greens is because I'd rather NOT have to up my dosage. I remain stable at 5mg daily. Prior to taking coumadin, I was a big salad eater..on a daily basis...that's why I miss it. Still, I prefer the occasional enjoyment of greens and keep my dosage as low as possible. I think many of us may do this, and still be properly nourished.

Zipper *~*
 
Zipper....

I was pretty close to being a vegetarian before my MVR. So, needless to say the transition was difficult. For the first two years, wouldn't touch anything high in K. As time went on I discovered how to enjoy my salads without the fear of having an incident.

Home testing makes it so very convenient. I take a straight 6MG or 6-1/2 depending upon what I eat. The funny thing is.....that is how I would fluctuate without eating salads.

Al's theory about having a small salad here or there has to be right on. I also drink an occasional glass or two of wine, a few times a month. It does not seem to effect my levels.
 
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Thanks

Thanks

Thank you Gina...I think if I had the home testing kit, I could experiment a bit and discover how I'd vary each time I had salad or two, or if indeed it wouldn't effect me. I guess it's the 'not knowing' that keeps me using caution that may not be needed.

My insurance company denied payment for home testing...so I'm hoping the price will eventually lower or I can buy one soon.

Zipper *~*
 
Hi Zipper

"I guess it's the 'not knowing' that keeps me using caution that may not be needed".

I hear you. Was very much a skeptic, cautious, etc when I could not experiment. Do hope more insurance companies start recognizing the 'savings' with patient home testing!

In my case, my provider covered my unit purchase but refused to pay for supplies, not even a portion. Ridiculous, huh? One box of strips runs me $90, 12 tests. One visit to the lab costs them exactly $90. Hummmm? Seems like a no brainier.

Have given up my battel as we have changed carriers and they don't cover a thing. Anyone know if Medicare finally approved INR home test units?
 
Hello. This is my first post. I'm in the process of trying to obtain a at home Inr test unit. Holy smokes!! you would think I'm asking for moon rocks or something!!! I had my "zipper" done back in 1995, spent a month in the hospital. Not due to surgery complacation but becasue they could not get my INR level to coperate, and it hasn't gotten any better!!!!. My INR levels have to be between 2.5 and 3.5 prefably 3 and above. So as you can tell I take "high" doses of coumadin, generally 10mg or higher a day. I get blood drawn every other week:mad: I guess my question is..... does anyone else have this much trouble in maintaing thier INR levels??
 
Merryreader,

I can identify with you!
I had two AVR surgeries within eleven days in August 2000. Second one because of a blood clot due to too low INR (1.4). The hospital sent me home with a prescription of Lovenox in addition to the Coumadin I was taking. My INR also did not come up as it should but they sent me home anyway. Well, we ran out of Lovenox and were unable to make contact with the cardiologist office other than getting their voicemail. We left 5 messages in total and when they finally got back to us I had missed three injections. The following morning I was in trouble and was back in the hospital and the whole surgery needed to be redone, including a new valve. If anyone had pointed out to us how important those Lovenox injections were we would have bought the Lovenox ourselves, but we had no idea. What did we know?
I bought my Protime unit after 6 months of being on Coumadin. Had to buy it myself because insurance refused to pay. The first 11 months I had a horrible time with my INR level. It also did not help to have a jerk for a doctor (regular PCP by then) who kept changing the dosages of Coumadin, was extremely rude to me and my INR kept jumping around. I was a nervous wreck every week! When I did not have the machine yet, I at times went to the lab two to three times a week. Really scary! And to try to get the office to call me back the same day is another story. It would help if doctors do this so the patient can start taking the adjusted dosage that same day. DUH!!!
When I got the Protime unit things got a bit better because I no longer had to run to the lab all the time. That doctor still kept changing the dosages, still was rude, and my INR still kept jumping around. INR=IT'S NEVER RIGHT!
Well, I ended up firing that doctor and found a new one, but before I was able to get in for an appointment I had to wait approx. 6 weeks, but I did just fine alone. I was a bit scared but I did fine! I have been stable since July of last year.
My new doctor keeps me on the same dosage pretty much, and that seems to do the trick for me. He also likes the Protime unit, knows how to regulate Coumadin and trusts me completely. I had to demonstrate to them that I was capable of operating the unit and getting INR results.
I am on 20 mg a day. God only knows how I metabolize vitamin K and Coumadin, but in order to stay safe thats what I need. My new doctor is also not afraid of an INR higher than 3.5. He doesn't want me to go over 5 he tells me, but anything under 5 is just fine. He believes it is easier to deal with a bloody nose than to suffer a stroke or blood clot. That can be fatal! I wholeheartedly agree. Been there done that!
I no longer have many problems with INR. I take a test once every two weeks, and unless I am low I don't retake it. At times I am a little high. Last week it was 4.8, but there were no problems with bleeding. He kept me on the same dosage. I just need to intake about the same amount of vitamin K every day and if I do that I am fine. I have not eliminated anything from my diet, and I eat a fair amount of greens daily.
The protime unit is great Merryreader. It will give you freedom! I am going on vacation soon and don't have to worry about finding a lab to go to. I love it!
If your doctor doesn't want to write the prescription for the Protime machine, find another doctor. You are the boss!

Go get em!

Christina
Aortic Stenosis
AVR's 8/7/00 & 8/18/00
St. Jude's Mechanical
Coumadin 20mg a day
 
merryreader,

The fact that you take about 10 mg of warfarin daily means that you are a fast metabolizer of warfarin. The significance of this is that you should never hold warfarin for more than one day, for an INR below 5 ( and maybe even higher). If you take about 5 mg of warfarin daily, your INR will drop by half every 48 hours that you do not take warfarin. If you take more than 5 mg daily, it will take less than 48 hours for your INR to drop by half. Less than 5 mg means it will take more than 48 hours.

This may be part of your problem, the person monitoring your warfarin may not understand this.

You might want to look at my website www.warfarinfo.com
 
Now that makes sense to me...when I had to have an ultrasound fine needle biopsy for thyroid, it took 3 days for my level to get low enough. I didn't realize the difference in how one metabalizes this. I just keep learing!!!

I know someone on coumadin that 'eats' marijuana in cooking ? Isn't this dangerous ? I tried searching the web on this but came up blank. This is a younger person that has 'smoked' it in the past. They seem to think it's not a problem...Yikes...anyone know ??? Sounds risky to me!!!

Zipper *~*
 
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