ACT Newb with Low INR

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Duff Man

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May 1, 2008
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Hi guys, long time no post!

I was diagnosed with a PE due to Factor V Leiden on 9/1/10, and I was put on 5mg of coumadin on 9/3, along with Lovenox 120mg BID. It's been 5 days and my inr is only 1.20, and that's what it's been since I was in the hospital. I just want to stop poking my stomach with 10 or 20 dollar shots as soon as possible, which means I need to get my INR higher asap.

My doctor hasn't called me to advise a dose adjustment yet, and each day that passes is more money and pain in the belly. Does anyone have any "if I were you"'s to help me get to 2.0? I was thinking about going to 7.5mg total instead of 5.0mg.
 
I was thinking about going to 7.5mg total instead of 5.0mg.

That's an awfully large increase. You've been on coumadin for less than one week and I would imagine it will take a little time to "load" your system. You might increase by 2.5mg x two, maybe three times per week. That should get your INR up a little quicker. Adjustments, normally, should be small. Large changes only cause "roller-coaster" problems. I've never used Lovenox, but as I understand that drug, it should keep you protected from stroke until you get your INR within your range.
 
That's an awfully large increase. You've been on coumadin for less than one week and I would imagine it will take a little time to "load" your system. You might increase by 2.5mg x two, maybe three times per week. That should get your INR up a little quicker. Adjustments, normally, should be small. Large changes only cause "roller-coaster" problems. I've never used Lovenox, but as I understand that drug, it should keep you protected from stroke until you get your INR within your range.

Point very well taken. You are probably one of the most experienced coumadin users here. Probably THE most.

The reason I was thinking 7.5 was because it was 1.15 on the second/third day and 1.20 on the fifth day... not much change at all.
 
Normally, I would agree with Dick's thought but, to be honest, in your case, I would probably be more aggressive. Factor V Leiden is definitely working against the effects of warfarin and your INR has barely moved. What's the range they suggested for you? I would think between 3.0-4.0. I don't think it would hurt to give it a good boost for a few days - test on the 4th day and see where it's heading.
 
Check this out. http://www.pace-med-apps.com/CoumCalc.htm

I punched in your numbers for an INR range of 2.0 - 3.0 and it indicates to increase 10 to 20%. For 4 days take 6mg, on day 5 - take 5mg, day 6 - take 6mg and on day 7 - take 5mg.
Four days of taking 6mg will give your body the boost it needs, retest on day 7 and see where your at.
 
Sounds like there may be more than a few ways to skin a cat!! :D

I like the logic of a 2.5 bump x2 or x3 days... seems reasonable to me. Since they came in 5mg tablets, it would've been hard to go with 6. :)

Random off-topic thought: I was diagnosed with Factor V Leiden about one month before I had a PE. My PCP scheduled my appt for the hematologist on 9/20/10, but it was about 19 days too late. I hate irony so much. Or is that a coincidence?
 
Actually Coumadin comes in Many Dosages which can be found by a Google Search (or your pharmacist).

I'm thinking 1, 2, 2.5, 3, 4, 5, 6, 7+, and others I don't remember.

Could you have a 'hidden' source of Vitamin K in your diet? (such as Ensure or other such drink?)

'AL Capshaw'
 
Actually Coumadin comes in Many Dosages which can be found by a Google Search (or your pharmacist).

I'm thinking 1, 2, 2.5, 3, 4, 5, 6, 7+, and others I don't remember.

Could you have a 'hidden' source of Vitamin K in your diet? (such as Ensure or other such drink?)

'AL Capshaw'

Thanks Al. Not real sure about hidden vitamin k. I try to eat as many veggies as possible with my meals, but I'm no vegetarian. I might randomly down a can of garbanzo/green beans, but it's not every day. My diet is fairly mediterranean/chinese based... honestly though, I wouldn't want to change it anyway. I'd rather dose the diet, as you guys have said.

My doc finally called today and instructed me to do 7.5mg on Tuesday and Thursday, all other days remaining 5mg. I was hoping he would say three days boosted a week. I just want to get this loading period over with. I'm not sure if he'll tolerate me usurping his authority by doing 3 days boosted instead of 2. I'll probably just roll with his dosing schedules for now until I get more comfortable. After all, he's the only one writing me a script for it right now.
 
Hidden K

Hidden K

The hidden K could be your issue. I had a lot of problems getting my INR to where we wanted it, 3 to 4. I was on Dr prescribed OTC vitamins and discontinued them. My INR came up quickly. All dark greens are loaded as well. By the way I am on 12 mg. I have been steady for 60 days now. Good luck getting to the level you need.

KartRacer
 
I'll probably just roll with his dosing schedules for now until I get more comfortable. After all, he's the only one writing me a script for it right now.

Good idea.....at least until you become familiar with warfarin. Get yourself a dosing guide, like the one Freddie suggested above. I use the Al Ludwick guide, but I am not sure it is still available. I have found that docs are more comfortable when they know I am using a dosing guide(protocol). Also get a seven day pill box to take the "did I or didn't I take my warfarin" out of the dosing equation. As for stocking warfarin....usually one or two different strengths can be split or combined to meet any dosing requirement. I only use 5mg tabs (0, 2.5, 5, 7.5, 10) to best fit my weekly requirement. That also reduces the chance of errors caused by multiple Rx's.
 
doc called because the inr is only at 1.55... so he's putting me at 7.5 every day but tuesday and thursdays, testing in a week. I'm thinking 9 or 10 is the magic number...

I nicked my face shaving today and it kinda dribbled if i touched it for most of the day. That was one of the first big examples of the efficacy of coumadin for me.
 
At 5 mg/day your weekly total comes to 35 mg

With an INR of only 1.55, it would appear that you are a 'high metabolizer' and need a higher dose.

Al Lodwick's Dosing Guide for an INR <2.0 with a target of 2.0 to 3.0 would be to increase your weekly dose by 10-15% and retest in 1 week. That comes to a weekly increase of 3.5 to 5.25 which doesn't seem like much of an incrase for such a low INR.

Your Doctor's recommendation of 7.5 X 5 + 5 X 2 = 47.5 represents a 12.5 mg increase for the week which is around a 35% increase for the week. Hopefully that will be enough. I would NOT want to try anything higher which could cause you to overshoot. If it doesn't get you in range, you can make another (hopefully small) adjustment next week after your next test.

As you see, finding the 'sweetspot' when first starting Coumadin can be 'challenging'.
From my perspective, it's best not to make adjustments that are Too Large to avoid/minimize the Roller Coaster Effect.

Let us know how it goes.

'AL C'
 
My wife started warfarin six weeks ago on 2mg daily. Hospital discharge from mechanical valve INR 1.9, then 2.1., then 2.3., then 2.0 and today dropped to 1.7. !! Daily greens intake not much change but started "ENSURE" milk powder one scoop daily. Also exercise activity has increased a fair bit. I wonder if the increased activity has increased the metabolism of warfarin and caused the INR to drop. The cardiologist has now increased to 2.5mg daily
 
It was probably the Ensure. Others have reported that Ensure has enough Vitamin K to drop the INR. The extra activity probably had a minor effect - if at all.

The advice here is to dose the diet not diet the dose. Once the INR is regulated, keep taking the Ensure -- and if your testing is being done by a clinic or lab, you should let the doctor know that she's taking Ensure. (If she stops taking Ensure, her INR could rise and you'll probably have to drop the dosage and retest every few days - or weekly - until it's back within range.

The doctor's increase to 2.5 daily may have been a bit drastic - on this forum, they usually recommend 5 or 10% increases - not the 25% the doctor ordered. When is testing scheduled next?
 
Ensure is Known to have enough Vitamin K to affect INR.

Increased Metabolism with increasing activity following surgery is also Known to lower INR and needs to be adjusted for to maintain the target INR. SMALL changes in dosing work best to avoid going into the dreaded Roller Coaster Effect.

'AL Capshaw'
 
I was pretty stable at 7.5mg x6 days and 10mg x 1 day for about 2 months with an inr of around 2.3-2.9, but I've been skimping on the veggies and now my INR is 3.9 as of this morning. I really didn't think my diet changed that drastically. The only other difference in meds is i recently started taking a benadryl once at night to sleep, probably in the last week and a half. The nurse called within a few hours of the test and asked me to reduce the 10mg x 1day to 7.5mg x 7days.

Is 3.9 dangerously high? It creeps me out when I get a headache at this range, but I have nothing to relate the numbers to. I'm told that sometimes cancer patients' normal INRs are in the 3.0-4.0 range, but.. that's for very sick people. Just wondering if I should be worried... and if the nurse's advice is sound.
 
According to the on-line INR calculator it reads - reduce 5-10%
New dosage:
Day 1 - 7mg
Day 2 - 7mg
Day 3 - 7mg
Day 4 - 7mg
Day 5 - 8mg
Day 6 - 7mg
Day 7 - 8mg

Check INR in 7 to 10 days,

Hope this helps
 
Most of our members consider 2.0 to 4.0 to be a relatively SAFE region so NO Need to Panic or over-react. A SMALL drop in weekly dose (5 to 15%) and retesting in 7 days is a reasonable course of action.

What is your Target Range?

What size (dose) pills do you have on hand?
 
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