Concerned with INR level

[Mercia]

Hello All,

Have a couple of questions regarding INR Therapeutic level maintenance requirements.
Any feedback would be greatly appreciated. Not sure I feel comfortable with my cardiologist’s guidance at this time – but not sure if I am missing something.

In November last year when my INR was 1.9, I was given the following guidance by my cardiologist:

"When the INR is low, there can be a higher risk of stroke. Though the risk is relatively low, it is still safer for you to take the Lovenox injections as you are doing. While INR target of 2.5 to 3.5 is ideal, Lovenox can be considered when INR is less than 2.0 (as yours currently is)").

On Feb 4th this year my INR was 1.7, and was confused when my cardiologist recommended against Lovenox injections to get my INR back in the therapeutic level – he gave the following explanation.

Cardiologist replied:

“When you have a new, fresh mechanical valve, it is very important to keep the blood adequately thin after surgery, until the Coumadin starts to work. Once the Coumadin is therapeutic, then the Lovenox can be stopped and Coumadin continued.

After a while, the mechanical valve gets coated with a thin layer of cells. This, in combination with the low profile mechanical valve, helps the valve be less thrombogenic (less likely to form clots) than the older, more traditional mechanical valves.

For some patients who have a mechanical valve and have an actively bleeding disorder, they can be off of Coumadin for days to weeks (due to active bleeding) and it is (fortunately) uncommon for them to have a stroke.

When you are on Coumadin, as you know, there can be some fluctuation. If your INR temporarily drops lower than desired, it is usually okay to just take a bit more Coumadin and get the INR back into therapeutic range. Lovenox is usually not needed unless you stop Coumadin for a longer period of time. It will be good to recheck the INR soon and make sure it comes up appropriately.

If it is below therapeutic for too long, then being on Lovenox in the interim is reasonable.”

PT INR results:
1/7/09 = 2.7 – dosage 5mg every day
1/21/09 = 2.3 dosage changed to 5mg every day except on Thursdays 7.5mg
2/4/09 = 1.7 – dosage changed to 5mg everyday except 10mg one time on Thursday 5th and 7.5 mg every Sunday and Thursday.
2/11/09= 1.9 – dosage changed to Mon, Wed and Fri – 7.5mg other days 5mg.

Next lab test is on 2/19.

I stopped using amiodarone, end of December after 6 months use for A-fib, as well as Metoprolol to control heart rate. It is my understanding that this change in medicine will cause INR to be all over the place.

Is my assumption correct that when not in INR therapeutic level, and the A-fib returns, the mechanical valve’s coating or type of valve profile will not provide me with any extra protection against having a stroke, or clotting.

Is there a timeline that is considered low risk being outside of INR therapeutic level for above scenario?

Cheers
Mercia
_______________________________________________________________
Minimal Invasive, Right Thoracotomy - Mitral Valve Replacement with On-X Mechanical valve and Modified Maze procedure on 06/24/2008

Successfully Electrical Cardioverted on 08/14/2008 for Atrial flutter

 

[Herb M]

I would never use Lovenox to get me to theraputic range. I would rely on adjustments to the doseage.

 

[Lisa in Katy]

I agree with Herb regarding Lovenox. I think that using it every time your INR is a little low is extreme and could cause bleeding issues. I don't know much about that valve, but it sounds like your physician knows something, or at least he talks a good game. He is also making minor adjustments up, which is good, as it will keep you from spiking and then trying to chase a number. Generally 10% adjustments are recommended. His are slightly lower, but still okay for someone so fresh out of surgery. As far as a safety zone, it's really a role of the dice. There have been some people who have been off ACT for years and do just fine, there are others who get low for a day or two and have a stroke.

 

[Bina]

I would never use Lovenox to get me to theraputic range. I would rely on adjustments to the doseage.

The Lovenox is not used to get you therapeutic.....only the Coumadin will do that.
Lovenox works in a different way, similar to Heparin, to protect you until you raise your INR correctly with Coumadin.

 

[dick0236]

Can't help with answers about Lovenox. I have been on warfarin 42 years and have never had a Lovenox shot.

Stopping the drugs you mentioned may very well screw up your INR and require significant warfarin adjustment.

Since your INR is not extremely low, I think your doc is correctly increasing your dosage slowly. So long as your INR is continuing to increase I would continue increasing the dose slowly until I got back in range.

 

[Mercia]

Thanks everyone for your feedback

As my recommended PT INR level should be between 2.5 and 3.5, should I not bridge with Lovenox until I reach a therapeutic level again or at least until I am above PT INR level of 2 to prevent a stroke?

Mercia

 

[Freddie]

The Lovenox is not used to get you therapeutic.....only the Coumadin will do that.
Lovenox works in a different way, similar to Heparin, to protect you until you raise your INR correctly with Coumadin.

Here's Bina's answer; Raise your INR correctly with Coumadin

 

[Bina]

When I was 3 weeks post op and my INR slipped down to 1.9 they had me get a Lovenox needle.
It's up to you and your doctor what action to take for 1.9 but that was 3 days ago anyway.
I would be testing again on Monday or Tuesday.

 

[Lisa in Katy]

As I said, I think that Lovenox is extreme except as a bridge if you have to go off Warfarin. It causes you to be double anticoagulated. Although 1.9 is low, perhaps it might reassure you to know that when I first got my mitral valve, the acceptable range was 2.0-3.0. 1.9 wouldn't have even merited an adjustment.

 

[TXGal]

I was on Lovenox shots for almost a month after my last surgery in 2000. I left the hospital when my INR still was not in range and was told that normally doesn't happen, but since I was up and walking sooner than most (I was 20) they let me leave and have a home health nurse come to my apartment in the morning and evening every day for about 3-4 weeks until my INR level was therapeutic. Since then, the only time I can recall being on Lovenox or Heprin shots was twice when I had to stop coumadin to (1) I have had ovarian cysts rupture and bleed internally pretty bad, so they removed me from coumadin and had the shots for a short amount of time and (2) I had to stay off of coumadin for about a week or two right before an egg retrieval for surrogacy.

 

[Karlynn]

I've never had Lovenox and my INR has been below 2.0, but never below 1.5. We've just always increased the dose and tested in 3 or 4 days. This doesn't mean you shouldn't use Lovenox, just a comment on how some are managed.

Like Lisa - for me there was a time when my INR level was 2 - 3.

 

[BDMc]

Mercia, Did you get it tested today? If so what was it? Hope you're in range. Brian

 

[Mercia]

quick update

quick update

My INR is still at 1.9 - after really looking more into the dosage adjustments that they made the previous week, I realised that they only shuffled the daily dosage around. The overall weekly dosage was still 42.5mg - which was the same as the previous week.

So my INR is now below 2.0 for 3+ weeks - but I am not as stressed out anymore after reading some of the feedback. Thanks again everyone.

They adjusted my weekly dosage now from 42.5 to 47.5mg - so will have to wait to see what the lab results shows on Monday 02/23.

 

[Eva]

My INR is still at 1.9 - after really looking more into the dosage adjustments that they made the previous week, I realised that they only shuffled the daily dosage around. The overall weekly dosage was still 42.5mg - which was the same as the previous week.

So my INR is now below 2.0 for 3+ weeks - but I am not as stressed out anymore after reading some of the feedback. Thanks again everyone.

They adjusted my weekly dosage now from 42.5 to 47.5mg - so will have to wait to see what the lab results shows on Monday 02/23.

Good luck and look forward to hearing an update from you with good news

 

[westie]

medical fact?

medical fact?

Hello All,

After a while, the mechanical valve gets coated with a thin layer of cells. This, in combination with the low profile mechanical valve, helps the valve be less thrombogenic (less likely to form clots) than the older, more traditional mechanical valves.

this is all news to me. has anyone else heard about the mechanical valve getting coated with a thin layer of cells causing the valve to be less likely to cause clots?

 

[tex]

Hi Mercia, My INR levels sound just like yours if they drop below 1.6 i have the injection for 3 days as well as the Warfarin, i was told that when its low i needthe injection as a quick way of thinning the blood the injection would not alter my INR level its just the Warfarin that does that. im so confussed by it all, i went last Monday and it was 3.6 i was told to take 10mg everyday and come back last friday my INR had dropped to 2.6 which is in my range, but even though it had dropped i was still told to take 10mg everyday and come back this friday, If it had dropped that much in 4 days why did they leave me on that dosage when i go back i bet it has dropped and if it has below 1.6 injection time again, im lost with it all just like you and after reading what people have wrote to you injection dont sound a good idea and these guys are here are the best, they have all been through what we are going through. If you get it sorted please let me? Hope you get sorted, Take Care Jane

 

[Bina]

My INR is still at 1.9 - after really looking more into the dosage adjustments that they made the previous week, I realised that they only shuffled the daily dosage around. The overall weekly dosage was still 42.5mg - which was the same as the previous week.

So my INR is now below 2.0 for 3+ weeks - but I am not as stressed out anymore after reading some of the feedback. Thanks again everyone.

They adjusted my weekly dosage now from 42.5 to 47.5mg - so will have to wait to see what the lab results shows on Monday 02/23.

Mercia, this just goes to show that the labs can mess up the dosing.....

If they have you on 47.5 mg weekly now, I'm assuming that your dosing is 7.5mg for 5 days and 5.0mg for 2 days.
Hopefully you have been starting off with mostly the 7.5mg doses to show an increase on your next INR test.

If you write down your daily doses and INR on a calendar, you will see very easily what you need to dose.
Let us know your next results. I'm sure you will be fine.