20 + yrs on Coumadin, now low INR's & Lovenox

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Gisele

Out of curiosity, has anyone had any difficulty having to take increased doses of Coumadin after extended use? I have been on Coumadin for more than 20 yrs and although my INR's have always been all over the place, lately I have been running low, and as a result have had to self inject Lovenox on & off for the past month or two. I can remember a few years ago, I could barely handle 5mg daily and now I am up to 10mg daily. Has this happened to anyone else? Beginning to wonder why my body is resisting.
 
uh oh I am already on 10mg/day,after 1 1/2 years, what will it be in 20 years?
Well, I will refuse to worry about this as I already have enough to bother me!!:)
Gail
 
I do not take warfarin but have been monitoring people on it full time for 4.5 years and run the website www.warfarinfo.com
I have some ideas that may help you figure this out.
Warfarin is only metabolized by the liver. Unless you had liver disease before and your liver function improved, it has to be something that you are doing different.
You would probably have figured this out by now if it were simply a matter of eating more vegetables now.
Have you increased your exercise level? This causes you to pump blood more efficiently through your liver and you metabolize warfarin faster.
I hope you haven't started chewing tobacco. I saw this once. It is a green, leafy vegetable and the person swallows a lot of vitamin K.
What about any herbs or natural products?
Have you changed any medication? People tend to overlook that stopping interacting medications can have just as much effect as starting them.
Consistency is the key to warfarin management. Look for something that has changed. I'd be interested to know what you find.
 
Thanks, but

Thanks, but

No to the liver disease, and not to worry I didn't take up chewing tobacco. Actually my exercise routine certainly has decreased due to my increase in migraine headaches (they last up to 5-6 weeks when I get them). I take Fiorcet and when needed percocet but that has always been the norm for me. I did start last week with Toprol XL 25mg hoping that this will prevent migraines, but was assured by my cardiologist that this is not affecting my INR. All other meds are the same. No drastic changes in diet other than due a wonderful very long and severe migraine I had last month I lost about 8lbs due to lack of appetite. One year ago I could barely take 5mg, slowly it went to 7/8/7/8, and this week up to 10mg. I just found this a bit concerning, as if I was developing a resistance to my lower doses. Does that ever happen or has Dupont ever studied this at all? Lets face it-how long has coumadin been around, and I am sure that there aren't too many patients left who have been on it as long as myself or even longer. Thanks for your replies.........
 
Hi Gisele-

My husband has been on Coumadin for 25 years, and there is at least another on this site that's been on Coumadin that long or longer.

His INR fluctuates, of course, as everyone else's does. He had surgery July 18 (his 3rd valve surgery), and is now starting to be more active, so he's going between 7 1/2 mg and 10 mg on a rotational basis and testing every week for a little while until it settles down. It must be the increase in his activities, because his other meds haven't changed much.
 
Gisele, You answered your question about the fluctuating INR and why your warfarin requirement goes up when you typed, "Fioricet". This contains butalbital which is one of the more potent inhibitors of warfarin action. Please look at http://www.warfarinfo.com/butalbital.htm I probably do not have this page worded strongly enough. Dangerous is a word that should be used for the exact reason that you state. You used to take 5 mg of warfarin and now you take 10. Over time the butalbital has stimulated the liver enzymes which metabolize warfarin. These enzymes are now burning warfarin at twice the rate they were previously. IN FACT, IF YOU STOPPED FIORICET COLD TURKEY NOW AND DID NOT DECREASE YOUR WARFARIN DOSE YOU WOULD PROBABLY HAVE A MAJOR BLEED WITHIN SEVERAL WEEKS TO MONTHS DEPENDING UPON HOW LONG IT TAKES YOUR ENZYMES TO RETURN TO NORMAL. You are in one of the most precarious positions that a person taking warfarin can get into. If you continue Fioricet you will continue to increase your need for warfarin probably indefinitely. If you stop Fioricet, you could bleed. You need very skilled professional help. Fortunately you are close (depending upon how far north of Boston you are) to some of the world's experts on warfarin. Dr. Jack Ansell, the head of our professional organization is in Boston. You can reach him at www.acforum.org and click on queries.
Please do not disregard this and do not settle for my opinion alone. From this site, you can send a private message to other members. The one I suggest that you send one to is MATXR. He is a retired (semi) physician who has a valve himself. Ask him his opinion of this.

I MUST REPEAT DO NOT STOP FIORICET COLD TURKEY. IT WILL PROBABLY TAKES MONTHS OF DOSAGE ADJUSTMENTS TO GET YOU OUT OF THIS PREDICAMENT, WHILE CONTROLLING YOUR PAIN WITH SOMETHING LESS DANGEROUS AND CLOSELY MONITORING YOUR INR AND ADJUSTING YOUR WARFARIN DOSES.
 
Absolutely astonishing Al. We are blessed to have your expertise!

Is Percocet and Fiorcet in the same family? I took Percocet after surgery.. Terrible time getting my INR up and under control in the hospital. Thinking back....when I came off of the Percocet....my INR shot up. Wonder if that is the reason? Could that combo cause one to tamponade?
Thoughts?
 
Gina
The only thing that they have in common is the -cet which stands for acetaminophen (Tylenol). Fioricet has a babrbituate in it which is the one that stimulates the liver enzymes to metabolize warfarin. Percocet has oxycodone, a narcotic that does not interfere with warfarin metabolism.
The two cases of tamponade that I have seen were probably caused by spots that did not stop bleeding after surgery. I do not think that they were caused by medications. In fact I know that one of them was not. That man's primary care doc is also my primary doc and I saw the patient with him in ICU and followed him all along. The other guy I never did get a good history on before he disappeared - he just quit coming to the clinic and I was unable to contact him.
I have three guesses as to what caused your INR to shoot up. You might have been getting total parenteral nutrition (TPN). This requires what is called a central line that goes into the superior vena cava just before it enters your heart. This is usually only used for people who will be unable to eat for 7 days or more. It is a white, milky looking IV bag. It provides all of the nutrients by IV to keep you alive indefinitely. It usually contains vitamin K.
Second guess, you were taking a supplement by mouth like Ensure or Boost or Resource. These are heavy in vitamin K. When people taking these get better and the things are stopped then the patient's INR goes haywire. I see this constantly in the hospital.
Third guess, they used one of the old protocols which called for using 10 mg doses to get the patient' INR up quickly. They usually overshoot.
If you combine one or two with number three, you have the makings of a very high INR.

Do you know what days the Las Vegas Reunion is planned for? I am seeking corporate sponsorship so that I will be able to attend. I may have to give a little commercial with a talk, but I am seeking a unrestricted education grant.
 
Hi Al

Thank you for your response. Yes, to Ensure, not after my MVR. But after the tamponade. Loading dose of Coumadin was used both times. The tamponade was three weeks post op. I hear this is usually bedside post surgery.

Would be an honor meeting you in Las Vegas. Believe dates are for Oct 9th-13th, 2002. Location TBA by Hank. Perry A is working on the meeting outline and visuals. You may wish to contact him when you confirm.
 
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Fioricet and warfarin

Fioricet and warfarin

Al, As far as I know Fioricet is NEVER prescribed post op to our
warfarin patients and rarely prescribed for anything else. These "barbitals" are not good drugs and can easily be abused. At least oxycodone which is being abused like crazy around here does not interact significantly with warfarin.As always I am impressed by your breadth of knowledge and how quickly you detected the problem as imbedded in Giselles 2-26 Email. You do good work!
 
Impressed!!!

Impressed!!!

Al,

Just a quick.."I Agree..I am very impressed with your knowledge" and very much appreciate your imput here!!!

Thank you so much,

Zipper *~*
 
Thanks

Thanks

Thank you for all your responses. Hopefully things will work out with my INR. I'm a bit nervous about being on 10mg daily right now, as if I go too high my dose will need to be adjusted and I want my INR stable. I am headed in less than two weeks to Australia for my son's wedding and I will be six hours from the largest city. I do not need complications with my INR. I am bringing my Protime machine, enough medication to cover any situation, and some Lovenox pre-filled syringes (just in case). This past month has been incredible with such low readings requiring Lovenox most of the time.
A big thank you to Allowick for your imput. This board is great.
Gisele
 
Hi Gisele

Lovenox is a 'good' thing to keep around in the event of an emergency, low INR.

Have had to resort to this once in the three years since my MVR. The other time I was low.... they admitted me and hooked me up the heparin. Probably a bit of overkill since this can easily be managed at home with the injections.

Leaving for the Bahamas in a few days. Expecting a messed up INR upon return. It's usually higher than lower because I do enjoy my fruit and tropical drink diet while vacationing.

Have a safe and happy trip. Enjoy the wedding!
 
Just to let you guys know that this site helps me in my everyday practice, too. I saw a woman today who has doubled her warfarin dose in a little over one year. Guess what she was taking? Fiorinal. The only difference from Fioricet is that this one contains aspirin.

We had a discussion that she is working herself into a dangerous position with an escalating warfarin dose and yet unable to stop the Fiorinal. I think that it is going to be very hard to wean her off the Fiorinal.
 
Sounds familiar....

Sounds familiar....

I have been running high INR's now that I am not on Fiorocet or Vicoden and I think by closely monitoring my INR's I can come down safely. You were probably correct in determining that my migraine med was the cause of my need for more Coumadin. Fortunately, my Toprol XL is working. I know how that woman must feel if she has migraines and that is why she is taking Fioronal. My headaches always started with an aura and would last for weeks (I think my longest was around 6 weeks). I would refuse to give up my pain meds too, as they enabled me to function on a daily basis. I wish her luck. Maybe a low dose beta blocker would help her too. It might be worth trying. She might need to see a neurologist in order to try different prevention treatments if she hasn't already done so. I guess we can all learn from one another. Thanks everyone. Gisele
 
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