INR dose - hard to trust a GP

[Meanjellybean]

Hello all,

I am finding it very difficult to trust my GP regarding my warfarin dose.

I recently had the following doses:


Inr dose

Fri Jun 04 2021	1.2​	2​
Sat Jun 05 2021	1.4​	2​
Sun Jun 06 2021	1.6​	2​
Mon Jun 07 2021	1.9​	2​
Tue Jun 08 2021	1.6​	2​
Wed Jun 09 2021	1.6​	4​
Thu Jun 10 2021	1.7​	4​
Fri Jun 11 2021	1.8​	5​
Sat Jun 12 2021	1.9​	5​
Sun Jun 13 2021	2.2​	4​
Mon Jun 14 2021	-	4​
Tue Jun 15 2021	2​	4​

So my INR is 2.0 and I was asked to continue on 4mg and not test for another week. I would feel alot safer taking 5mg as my INR is dropping on 4mg. I am also on antibiotics which can have an affect. Also I dont have a home monitoring kit yet. I have one being ordered.
When I expressed my concern to the GP he was casually saying it's fine and that if you have symptoms while it is low he will review then.. but I am like.. symptoms while low means a stroke or thrombosis!

Any advice is appreciated and I dont think I can wait a week for testing considering I am still new on my dose.

I dont think I will be able to trust the GP but am I jumping a little early.

@pellicle your input is gold.

Cheers

 

[Warrick]

Do you have a coaguchek meter or intend to buy one? Are you planning on self management?

Looks pretty clear your dose needs to go up a bit.

 

[Meanjellybean]

Do you have a coaguchek meter or intend to buy one? Are you planning on self management?

Looks pretty clear your dose needs to go up a bit.

Yes 100% plan to do my own testing and self management.

Just have not yet received it.
It does seem pretty clear doesn't it. Then why does the GP not see the same? It's crazy the amount we need to trust these people. And the consequences fall on us for their mistakes.

F@%$ that!

 

[Chuck C]

Hello all,

I am finding it very difficult to trust my GP regarding my warfarin dose.

I recently had the following doses:


Inr dose

Fri Jun 04 2021	1.2​	2​
Sat Jun 05 2021	1.4​	2​
Sun Jun 06 2021	1.6​	2​
Mon Jun 07 2021	1.9​	2​
Tue Jun 08 2021	1.6​	2​
Wed Jun 09 2021	1.6​	4​
Thu Jun 10 2021	1.7​	4​
Fri Jun 11 2021	1.8​	5​
Sat Jun 12 2021	1.9​	5​
Sun Jun 13 2021	2.2​	4​
Mon Jun 14 2021	-	4​
Tue Jun 15 2021	2​	4​

So my INR is 2.0 and I was asked to continue on 4mg and not test for another week. I would feel alot safer taking 5mg as my INR is dropping on 4mg. I am also on antibiotics which can have an affect. Also I dont have a home monitoring kit yet. I have one being ordered.
When I expressed my concern to the GP he was casually saying it's fine and that if you have symptoms while it is low he will review then.. but I am like.. symptoms while low means a stroke or thrombosis!

Any advice is appreciated and I dont think I can wait a week for testing considering I am still new on my dose.

I dont think I will be able to trust the GP but am I jumping a little early.

@pellias your input is gold.

Cheers

I agree with your math, that it does not make sense to stay at 4mg.

The Coumadin Clinic was assisting me with dosage and testing early on. They would get the results from the lab and tell me their recommendation for dosage for the next few days. I usually agreed with them, but a couple of times I disagreed and took the dose that my math told me was the correct dose. Then I got my Coaguchek and starting self testing about 2 weeks out of surgery. They asked me to call them weekly with my results and they would tell me how many mg I should take.........and I pretty much ignored their guidance and kept taking the dose that I thought was right. To be clear, there was no situation like yours, in which they seemed to clearly have it wrong, it was more like them telling me to take 3, 3, 3, 4, 4, 4, 3 and I would break one in half and take 3.5mg per day to be more consistent.

As all are aware, Pellicle is the guru in this area and hopefully he will weigh in with his thoughts. Personally, if my GP was giving me guidance that I thought could put me out of range, I would dose whatever I thought was appropriate. He might get his feelings hurt a little, but if his dosage is wrong, you are the one at risk of thromboembolism, not him. And, I would trust the recommendation of the experienced members of this board with warfarin dosing over most any doctor, especially when it comes to guidance from Pellicle.

 

[dick0236]

You are testing INR every day? That's a waste of time, money and strips. By the time your adjustments take effect, you have changed to a different dose. Wait 3-4 days between testing to get accurate results of your change. What is the INR range that you and your doc are shooting for? I am not familiar with your valve. If its 2-3 then 4 to 5 mg/day seems a likely dose but the current use of the anti-biotic could be affecting your INR. Your results would not cause me to write off this doc.....except he is testing you too often to get a meaningful dose.

 

[Meanjellybean]

You are testing INR every day? That's a waste of time, money and strips. By the time your adjustments take effect, you have changed to a different dose. Wait 3-4 days between testing to get accurate results of your change. What is the INR range that you and your doc are shooting for? I am not familiar with your valve. If its 2-3 then 4 to 5 mg/day seems a likely dose but the current use of the anti-biotic could be affecting your INR. Your results would not cause me to write off this doc.....except he is testing you too often to get a meaningful dose.

Hey @dick0236
I should clarify, I just had my valve put in 2 weeks ago. So they test every day in hospital before I could be discharged.
They are still finding my levels..

 

[Meanjellybean]

I agree with your math, that it does not make sense to stay at 4mg.

The Coumadin Clinic was assisting me with dosage and testing early on. They would get the results from the lab and tell me their recommendation for dosage for the next few days. I usually agreed with them, but a couple of times I disagreed and took the dose that my math told me was the correct dose. Then I got my Coaguchek and starting self testing about 2 weeks out of surgery. They asked me to call them weekly with my results and they would tell me how many mg I should take.........and I pretty much ignored their guidance and kept taking the dose that I thought was right. To be clear, there was no situation like yours, in which they seemed to clearly have it wrong, it was more like them telling me to take 3, 3, 3, 4, 4, 4, 3 and I would break one in half and take 3.5mg per day to be more consistent.

As all are aware, Pellicle is the guru in this area and hopefully he will weigh in with his thoughts. Personally, if my GP was giving me guidance that I thought could put me out of range, I would dose whatever I thought was appropriate. He might get his feelings hurt a little, but if his dosage is wrong, you are the one at risk of thromboembolism, not him. And, I would trust the recommendation of the experienced members of this board with warfarin dosing over most any doctor, especially when it comes to guidance from Pellicle.

Thanks @Chuck C
Yes once I do have a clearer understanding of my levels and the way they move I will most likely take control just as you did.
I will follow the GP for now but I will test myself in the next day or two.. I would be filled with too much anxiety to be able to wait a week like my GP suggested.

 

[Amy]

My first week at home, trying to agree with the ‘Coumadin clinic’ on what my dosage change should be when I was out of range, was ridiculous. They clearly didn’t know much about warfarin or INR, didn’t care enough about me to find out, yet didn’t want to give away any authority on decision-making (liability concerns I guess). I can’t even remember what crazy, inconsistent doses they suggested, only to change their mind when I questioned them, then get confused trying to calculate a dose; all the while insisting that having pills in two different dosages was going to complicate things beyond what I could handle. All very silly.

Checking your INR every couple days is a good idea till you get stable above 2.0 I think. I’m 10 weeks post op and still have been checking twice a week for the most part (mainly because my INR fell to 2.0 once after a week when I was guessing it’d be 3.0-3.4... and that’s made me a bit more cautious.)

if I were you, based on the table you provided, I’d probably take 5mg a day; then if you go out of range, drop it down to 4.5mg/day. But this is based on not taking any meds... I don’t know, with antibiotics - do they lower or raise INR?.. also I don’t know your range; are you one of us 2.5-3.0ers? ; )

don’t worry. You’ll get the hang of it and it’ll be a piece of cake.

 

[Meanjellybean]

My first week at home, trying to agree with the ‘Coumadin clinic’ on what my dosage change should be when I was out of range, was ridiculous. They clearly didn’t know much about warfarin or INR, didn’t care enough about me to find out, yet didn’t want to give away any authority on decision-making (liability concerns I guess). I can’t even remember what crazy, inconsistent doses they suggested, only to change their mind when I questioned them, then get confused trying to calculate a dose; all the while insisting that having pills in two different dosages was going to complicate things beyond what I could handle. All very silly.

Checking your INR every couple days is a good idea till you get stable above 2.0 I think. I’m 10 weeks post op and still have been checking twice a week for the most part (mainly because my INR fell to 2.0 once after a week when I was guessing it’d be 3.0-3.4... and that’s made me a bit more cautious.)

if I were you, based on the table you provided, I’d probably take 5mg a day; then if you go out of range, drop it down to 4.5mg/day. But this is based on not taking any meds... I don’t know, with antibiotics - do they lower or raise INR?.. also I don’t know your range; are you one of us 2.5-3.0ers? ; )

don’t worry. You’ll get the hang of it and it’ll be a piece of cake.

Thanks Amy, yes I did find in was not in agreement with my Doctor. I will give him the benefit of the doubt for this week but if it does drop I wont be happy.
By my calculations I should be at 4mg to 5mg. And if dropping I would be at 4.5 mg.
Antibiotics can affect INR in both ways depending on how the body reacts. Well that's what my pharmacist said. I'm not sure just yet how it affects me.

My target inr is 2.0 to 3.0.

Yes I still need to get the hang of all this. The sooner I get my home testing machine the better.

 

[Warrick]

Be aware to being freshly post op generally your dose takes a couple of months to settle. Many of us experienced this.
I started on 5mg and slowly worked my way up to 9mg over several weeks.
My dose has varied between 8.5-10.5 mg a day over the years.
I haven’t had an antibiotic yet (apart from miconazole..avoid that one..INR 7.7 lol) affect my INR, the only conclusive things I have found are alcohol (drinking every day for a few days) and paracetamol again taken every day for a few days last time I had a new tooth filling that ached.

 

[pellicle]

Hello all,

I am finding it very difficult to trust my GP regarding my warfarin dose.

I dont think I will be able to trust the GP but am I jumping a little early. I agree that the ramp up was too slow but its pretty common to start in slowly on introducing warfarin (and I recall you had some pre-dispositions which were complicating. There is something you DO NOT WANT TO GET (link) possible from just hammering in warfarin fast at the start.

@pellicle your input is gold.

weirdly I never got a notification! Its also weird that it has the @ before my name when it shouldn't.

Now I see that you're just been released ... this is not dosing by the GP then its dosing by the hospital pre release ... no?

I notice this with all the ones you've mentioned in

anyway,

I should clarify, I just had my valve put in 2 weeks ago. So they test every day in hospital before I could be discharged.
They are still finding my levels..

ok ... at this point you should just trust them ... and its not appropriate that I get involved at this time.

However its weird that they started you on 2mg ... I can't imagine why.

By my calculations I should be at 4mg to 5mg.

so, please give me a run through on your calculations ...

remember first it takes time for the dose to get into your system (this is 4 days)

then there is a delay on the actual INR obtained (usually lagging behind by 2 days)

I just had my valve put in 2 weeks ago. So they test every day in hospital before I could be discharged.

so are you home yet?

PM me and we can discuss this by phone if you wish

 

[pellicle]

I started on 5mg and slowly worked my way up to 9mg over several weeks.

indeed ... I was released on 4mg and got to 7.5 over a few months

 

[pellicle]

Any advice is appreciated and I dont think I can wait a week for testing considering I am still new on my dose.

your dose has been increased, your inside therapeutic range (which is more than I can say for one poor soul here recently who was released on INR<1.4 and not told to do anything) so just be "patient" and see where it goes. Even if it drops to 1.8 (which it might) that's not really an issue in such a short period)

a week is entirely suitable for retesting ... it takes time for INR to change (its not like an electron or a photon jumping all over the place, it has inertia)

 

[NorthWoods]

Hello all,

I am finding it very difficult to trust my GP regarding my warfarin dose.

I recently had the following doses:


Inr dose

Fri Jun 04 2021	1.2​	2​
Sat Jun 05 2021	1.4​	2​
Sun Jun 06 2021	1.6​	2​
Mon Jun 07 2021	1.9​	2​
Tue Jun 08 2021	1.6​	2​
Wed Jun 09 2021	1.6​	4​
Thu Jun 10 2021	1.7​	4​
Fri Jun 11 2021	1.8​	5​
Sat Jun 12 2021	1.9​	5​
Sun Jun 13 2021	2.2​	4​
Mon Jun 14 2021	-	4​
Tue Jun 15 2021	2​	4​

So my INR is 2.0 and I was asked to continue on 4mg and not test for another week. I would feel alot safer taking 5mg as my INR is dropping on 4mg. I am also on antibiotics which can have an affect. Also I dont have a home monitoring kit yet. I have one being ordered.
When I expressed my concern to the GP he was casually saying it's fine and that if you have symptoms while it is low he will review then.. but I am like.. symptoms while low means a stroke or thrombosis!

Any advice is appreciated and I dont think I can wait a week for testing considering I am still new on my dose.

I dont think I will be able to trust the GP but am I jumping a little early.

@pellicle your input is gold.

Cheers

Consistency is the key. Bi-Weekly testing for the first few weeks is good. After 3-4 weeks, then weekly testing. Right now I am at 24mg a week. 5 days I take 4mg and the other two, 2mg. It took the INR clinic 2 months to figure out what to have me at. I eat normal, drink normal, INR is steady at 1.7-2.0
It takes a few days for the Warfarin dose to change your INR. Be patient and it will stabilize.

 

[Superman]

Being so early in your recovery from the trauma that your body has just been put through, it’s no surprise that dosing and outcomes are a challenge. It takes a while for your metabolism to settle down during recovery. I agree with others that for now, it’s time to follow instructions and have patience.

The only guidance that really raises my concern is when they start holding doses and doubling doses. Then I lose confidence and second guess. But even that can be situational.

 

[Chuck C]

Be aware to being freshly post op generally your dose takes a couple of months to settle. Many of us experienced this.
I started on 5mg and slowly worked my way up to 9mg over several weeks.

This has been my exact experience. I'm 12 weeks on warfarin and I have had to increase my dose gradually over these weeks. Fresh out of the hospital 3mg kept me at 2.8-3.0 INR. Currently, I need about 6mg to keep me at 2.8-3.0 INR. It is interesting how the ramp up has worked. I will be stable for a couple of weeks and then suddenly I need an extra 1/2 mg to stay in range. One week my dose increased by 1mg to stay in range, or about 20% of my previous dose.
Pellicle informed me to expect this as my body adjusts to warfarin. Another factor for me is that I was on amiodarone for my first 4 weeks after surgery, which drastically amplifies the effect of warfarin, raising INR. Going off of amiodarone meant needing significantly more warfarin to stay in range. However, it is a gradual increase, as amiodarone has a very long half life of between 60 and 120 days. UpToDate

That is for long term use and I was on it short term, so hopefully I am on the lower end of that, but this would suggest that I probably still have amiodarone in my system, even though I have been off of it for 2 months, and it very well could be interfering with my warfarin clearance still. When this is coupled with the natural adjustment to warfarin in the first few months, I will not be surprised if I continue to need a bit more warfarin to stay in range. As my equilibrium is a bit in flux, I am testing every 3-4 days, but expect to gradually move that to every 7 days once things start to level out more.

Despite my increasing warfarin need, I have still managed to stay in range the vast majority of the time, as I can usually make my adjustments as I near the low end of my range before it dips under, one of the benefits of testing frequently in the early months after surgery.