What are the risks from an elevated INR?

[rmn]

Hi all,

6 weeks out of surgery. The results from my last "blood draw" INR test were 3.8, and the doctor's assistant called to tell me to drop down on the dosage on certain days of the week. However, I told her that two days before her call at my cardiologist's office, a test done with a CoaguChek machine read 3.1. I asked her to please consult with the surgeon again to make sure he still wanted me to drop the dosage given the more recent (lower) test result.

My question is this...if my doctor wants me between 2.5 and 3.0, what is the harm in being in the low 3's periodically or even on a regular basis? Seems like If you're going to be out of the range, isn't being on the high side better?

I've read enough here to know that some docs will have you changing dosage routinely and chasing INRs all over the place. From my newbie point of view, it seems that it's like the old stock market warning - "past performance is no guarantee of future results". Or am I just being naive about this?

Also, someone please correct me... My Rx benefits require Warfarin instead of Coumadin - isn't Coumadin just the brand name of warfarin? I thought they were the same pharmacologically (if that's even a word!).

Thanks

 

[Barry]

Dangers of an elevated INR is bleeding. Danger of a low INR is stroke. An aphorism around here I rather like is "Blood cells are easier to replace than brain cells." - i.e. it's better to error on the side of a high INR than a low one. Although you can get a hemmorragic stroke, too - i.e. internal bleeding in your brain - if you've got a high INR and you suffer a head injury; father of a friend of mine accidentally banged his head against the wall pretty hard while on Coumadin and it killed him.

I've got an artificial mitral valve, my INR is supposed to be in the range of about 3.0 to 3.5, in Eurpoe apparantly the standard would be up to 4.0. Mitral artificial valves apparantly have greater risk of clotting, so call for higher INR's. Point of all that being that with 3.8 you're still below the European range for a person with an artificial mitral valve, so I wouldn't worry about it.

I've found that brand-name Coumadin gives me a more stable INR than generic Warfarin. Alas, as did your insurance company, I've also found that brand-name Coumadin is more expensive, so I take Warfarin: In the next life, I'm coming back as rich instead of good-looking.

 

[Nancy]

Joe's been on Coumadin for 28 years. It ALWAYS fluctuates, even probably from one hour to the other. That's why INR's nickname is "It's Never Right"

Sounds like your doctor is doing OK with management. It takes three days for whatever you do with your dosage to show up in your test. Dropping down a little is reasonable.

Joe's learned to just go with the flow. The adjustments are not instantaneous and they should be done gradually.

From time to time here, we see some lulus of dorky dosages, but it doesn't seem the case here.

Should straighten out in a few days.

 

[Guest]

Your doctor setting a narrow range then sets you up for being out of range a lot of the time. It is hard enough keeping in a 1.0 wide range. Setting a 0.5 wide range just means additional frustration.

The 0.5 unit range is not recommended by any panel of experts that I know of. Your doctor is just making something up without understanding how warfarin works.

Many doctors try to keep their patients on a low range without thinking through what they are doing. The low range increases the risk for a stroke. If they thought this through they would see that what they are telling you is that they would rather that you had a stroke than a bloody nose.

Changing the warfarin dose when the INR is 3.8 is like panicking when driving 38 in a 35 zone.

My prediction is that you are in for a roller-caoster ride with this type of management. You will really come to believe that "It's Never Right".

 

[terryj]

My husband had Aortic valve replacement 3 1/2 years ago. His INR stays pretty much in range now. The doctors office left me Voice Mail this morning at work. His INR is 3.6 and the instructions were to eat a few extra greens this week. I like that answer and its what we would have done anyway. It took a while but I finally got the doctor to agree with our way of thinking on how to manage his coumadin.

 

[Don Giaquinto]

Don Giaquinto

Don Giaquinto

6 weeks out of surgery. The results from my last "blood draw" INR test were 3.8, and the doctor's assistant called to tell me to drop down on the dosage on certain days of the week. However, I told her that two days before her call at my cardiologist's office, a test done with a CoaguChek machine read 3.1. I asked her to please consult with the surgeon again to make sure he still wanted me to drop the dosage given the more recent (lower) test result.

My question is this...if my doctor wants me between 2.5 and 3.0, what is the harm in being in the low 3's periodically or even on a regular basis? Seems like If you're going to be out of the range, isn't being on the high side better?

I've read enough here to know that some docs will have you changing dosage routinely and chasing INRs all over the place. From my newbie point of view, it seems that it's like the old stock market warning - "past performance is no guarantee of future results". Or am I just being naive about this?

Also, someone please correct me... My Rx benefits require Warfarin instead of Coumadin - isn't Coumadin just the brand name of warfarin? I thought they were the same pharmacologically (if that's even a word!).

Thanks

I am four weeks post op today. I had the two bagger {aortic valve and aortic anyerism.} My first INR, about 1 week post op was 3.4 which I was told was very good. The day before Easter my Dr called to give the results of my latest INR and told me that I needed to ge the E.R..........now! It was 7.6.

In the E.R. it had gone down to 4.5. I was told to alternate between 5mg and 2.5 mg every other day. I was told that the desired INR is between 2.5 and 3.0. Take that for what it's worth. In my novice opinion, if my INR bounced between 2.5 and 4.0 it would not concern me even a little.

I also see from reading some of the posts in this sight that excerise affects the INR and causes it to drop. I was extremely active before the operation and am waiting with baited breath to return to my life style. But, the INR level will factor in and apparently will need to be closely monitered.

Don G

 

[Ross]

The day before Easter my Dr called to give the results of my latest INR and told me that I needed to ge the E.R..........now! It was 7.6.

In the E.R. it had gone down to 4.5. I was told to alternate between 5mg and 2.5 mg every other day. I was told that the desired INR is between 2.5 and 3.0.
Don G

Unless you were bleeding, sending you to the ER was a bit drastic. All you really needed to do was hold a dose or two. As Al pointed out above, a .5 window is virtually impossible to maintain. Someone better start educating these Doctors concerning how Coumadin works, this is beyond ridiculous now.

Your novice opinion is dead on! I'd be happy anywhere in that range.

 

[Guest]

My CoaguChek-S only reads up to 8.0. Above that it says greater than 8.0. I have seen 8 people with this level this month. All were treated by holding 2 doses of warfarin. None had any bleeding. All had doses restarted about 20% lower than before. We were unable to find a reason for any of them except one man whose doctor switched him from 2 mg to 5 mg when he was hospitalized.

 

[Marty]

Get a monitor!

Get a monitor!

My advice: Start to work to get a self testing monitor. Learn how warfarin works for you. We are all different. Then when you feel confident start regulating your own dose. You will learn more about yourself than any doctor or nurse can ever know. I'm a mitral too. For the first few years after surgery I kept my INR on the high side- 3.5-4.5. Last November I fell and got a bad bleed into my leg. I had to hold for three days to help stop the bleed and then started warfarin gingerly and got up to INR 2.5. I'm now keeping the INR 2.5-3.0 with the help of weekly testing by my Coaguchek No trouble so far. My average weekly dose varies between 19.5 to 21 mgm. Amazing to me is the fact that changing the weekly dose by 1 mgm can send my INR up or down. This would not be the case for a young rapid metabolizer.The Oracle at Delphi advised " Know yourself". Still true today.

 

[Toronto Guy]

We are all different....My average weekly dose varies between 19.5 to 21 mgm. today.

I am now popping 18 mg/day - and my INR is 2.9

 

[lance]

Hi all,

6 weeks out of surgery. The results from my last "blood draw" INR test were 3.8, and the doctor's assistant called to tell me to drop down on the dosage on certain days of the week. However, I told her that two days before her call at my cardiologist's office, a test done with a CoaguChek machine read 3.1. I asked her to please consult with the surgeon again to make sure he still wanted me to drop the dosage given the more recent (lower) test result.

My question is this...if my doctor wants me between 2.5 and 3.0, what is the harm in being in the low 3's periodically or even on a regular basis? Seems like If you're going to be out of the range, isn't being on the high side better?

I've read enough here to know that some docs will have you changing dosage routinely and chasing INRs all over the place. From my newbie point of view, it seems that it's like the old stock market warning - "past performance is no guarantee of future results". Or am I just being naive about this?

Also, someone please correct me... My Rx benefits require Warfarin instead of Coumadin - isn't Coumadin just the brand name of warfarin? I thought they were the same pharmacologically (if that's even a word!).

Thanks

Hello Toronto Bob

I'm a newby to Coaguchek S and have just finished supervised training at TGH.

We do a veinous and a capillary draw within a few minutes. The results have never been the same with the Coaguchek reading higher than the lab on all occasions. Strange yours was the reverse. I wonder why. I don't know if it makes a difference but I only use brand name warfarin because the pills are easier to break for a halfe dose.

Second question is why 2.5-3.0. I thought all valves required 2.5-3.5.

Cheers

 

[Ross]

2.5 to 3.5 is the recommendations set forth, but Doctors get the final call.

Lance, next time you do both tests, see what the clotting seconds are on the coagucheck and see if the lab can provide you that figure also.

 

[lance]

2.5 to 3.5 is the recommendations set forth, but Doctors get the final call.

Lance, next time you do both tests, see what the clotting seconds are on the coagucheck and see if the lab can provide you that figure also.

Thanks Ross good point.

Every time I do a test on Cogucheck S I keep a log of everything (the electronic quality control and how many seconds it took me to deposit a blood drop on the cup) just in case.

 

[Ross]

Does it show or give you the opportunity to display seconds as well as INR? I think the difference between lab and strip is going to come down to ISI indexing. As long as the time in seconds is relatively close together it shouldn't be a problem. The INR index was supposed to even the field so to speak between the ISI indexes, but honestly, I don't think it does.