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Coumadin dosages - spread out increases or do all in one day?

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slipkid

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I have a question about Coumadin dosing.

I was at 5mg a day but my INRs were too low (less than 2.0). The target range for my On-X valve is 2.0 to 3.0 btw.

The current doctor office managing my INR is having me take an extra 2.5mg a week but doing so all in one day per week by taking 7.5mg for that day instead of distributing that extra dosage around through the entire week (like say taking 5.0, 6.0, 5.0, 6.0, 5.0, 5.5, 5.0 or something similar).

My own GP doctor said if he was managing my INR he would spread the extra amount around, not take an extra 50% on one day. But he is not directing me to try to "fight" for this with the other doctor's office. From what I've been reading, and what seems to make sense to me, is that it is better to spread it around to try to get that good stable constant INR rather than spike up after the one day with extra 50% & be sliding down for the next 6 days.

Opinions?
 

pellicle

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Hi

The current doctor office managing my INR is having me take an extra 2.5mg a week but doing so all in one day per week by taking 7.5mg for that day instead of distributing that extra dosage around through the entire week (
...
From what I've been reading, and what seems to make sense to me, is that it is better to spread it around to try to get that good stable constant INR rather than spike up after the one day with extra 50% & be sliding down for the next 6 days.
I agree, the Dr suggesting taking 2.5 in one hit has no idea of the pharmakokinetics of Warfarin. There will be a spike (which is not ideal) and then it will likely drop a wee bit lower then come back to where it was.

Why? - Warfarin has a half life of only a couple of days. Meaning that the benefits of the extra dose can only be there for a short time.

Personally I've seen that adding 0.5mg mg to my dose every day can have a clear measurable effect in a few days and it raises my INR gently. Note the small changes in warfarin dose (I take the same dose every day and will divide my 1mg tablets into 4 if I need to get such.



Note also that the biggest INR fluctuations occur when I had the biggest dose changes (and the earlier ones in 2013) were under protest but under Dr directions (I was in Hospital and had no control over this).

Thats my opinion (and I agree with your 2nd Dr)
 

tom in MO

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With me, they made changes in daily doses in the beginning. But after my inr was relatively stable, they did single day adjustments with two week testing. Just last week my inr was 2.8, so i was told to do a half dose (2.5mg lower i take 5mg a day) to bring me down to the 2-2.5 range. I'd not second guess or micromanage the situation unless there is something more serious going on.
 

dick0236

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I have a question about Coumadin dosing.

I was at 5mg a day but my INRs were too low (less than 2.0). The target range for my On-X valve is 2.0 to 3.0 btw.

The current doctor office managing my INR is having me take an extra 2.5mg a week........ like say taking 5.0, 6.0, 5.0, 6.0, 5.0, 5.5, 5.0
Opinions?
I agree that taking the extra 2.5mg all at once is not what I would do either and it will cause spikes in your INR a few days later and if you test on that day your INR will be high and a Yo-Yo will get started. Your proposed schedule above makes sense to me. I try to keep my daily doses as similar as possible. I had a similar problem several months ago and my doc increased my dose by 1mg three times per week(M-W-F). I choose to break the 1's in half and take an extra 1/2mg six days per week. My seven day billbox makes my dosing schedule a breeze.

Maybe your doc is trying to keep your Rx costs down by simply splitting a 5 in half....or many docs are concerned that some of their patients will get confused and take the wrong dosages
if they have multiple Rx's. Once your doc sees that you can "walk and chew gum at the same time" they should allow you to participate in YOUR INR maintenance program.....another reason to self-test
 

Protimenow

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I am in full agreement with your second doctor. A one time change that drastic demonstrates a lack of understanding of the way that Warfarin works -- your doctor apparently relies on 'weekly' dosage totals and doesn't realize that this really isn't how it should be done. Why not just take the FULL WEEKLY DOSE all on one day?

I've done testing that showed (to me, at least), that the INR DOES fluctuate, based on the days that you test and the day that you take a different dose. If at all possible, take the SAME dose each day. This should help make your INR pretty stable.

DO listen to the second doctor -- he or she appears to have a better understanding of anticoagulation management than the other one.
 

slipkid

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I am in full agreement with your second doctor. A one time change that drastic demonstrates a lack of understanding of the way that Warfarin works -- your doctor apparently relies on 'weekly' dosage totals and doesn't realize that this really isn't how it should be done. Why not just take the FULL WEEKLY DOSE all on one day?

I've done testing that showed (to me, at least), that the INR DOES fluctuate, based on the days that you test and the day that you take a different dose. If at all possible, take the SAME dose each day. This should help make your INR pretty stable.

DO listen to the second doctor -- he or she appears to have a better understanding of anticoagulation management than the other one.
Thanks for your input.

I had tried to ask about this to the cardiologist's office via voicemail (along with other things) on Friday and in response to that they called today & said they want to see me in person to discuss things. So I will try asking about this face to face in that appt. (tomorrow).

At this point I fear they do not understand the finer points of INR management, and just even bringing it up will be interpreted & handled as "this patient thinks he knows everything and he is a pain in the ass".

Note that I thought I had this behind me when my GP specifically told me that as a matter of policy when his office manages INRs they do not give out greater than a 1 mg increase per day like this, that they instead spread out whatever the increase is across an entire week then test to verify the patient is in the right INR range & tweak from there. At that point it he left the situation as "get back to us with what the cardiologist's office says to do next and if I do not agree then we will handle your INR instead". But then when I told later him they were upping me 2.5mg on one day a week, which was against his own office's policy from what he told me before, and me thinking he would respond with "OK we'll handle your INR from now on, I'll let the other Dr. know" instead his response was "OK I agree with that, just do it their way". I was left speechless by that response.

Thus my dilemma now of which I am trying to gather info/evidence to try to educate the cardiologist's office. I believe that the folks in charge of monitoring my dosage/INR (cardiologist's office) are not doing it correctly but I am not a doctor. In my experience health professionals do not take it well when a patient points out something that they may be doing wrong though.

I have been researching this for days on the 'net but haven't really found anything super concrete to back up my belief that a 50% increase in warfarin is best spread across multiple days than taken in one shot on one day a week (as a maintenance approach as opposed to a needed boost for other circumstances). If anyone knows of anything like medical research/literature on the 'net that discusses this I would appreciate the heads up so I can bring info with me to show them.
 

dick0236

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At this point I fear they do not understand the finer points of INR management, and just even bringing it up will be interpreted & handled as "this patient thinks he knows everything and he is a pain in the ass".......

.....Thus my dilemma now of which I am trying to gather info/evidence to try to educate the cardiologist's office. I believe that the folks in charge of monitoring my dosage/INR (cardiologist's office) are not doing it correctly but I am not a doctor. In my experience health professionals do not take it well when a patient points out something that they may be doing wrong though.
.
Yep, this is exactly my experience over the years. I tried using a cardio INR lab for about a year, four or five years ago. After too many warfarin battles concerning what was best for ME, I left their lab and went back to my GP for management....after all, it IS NOT rocket science. I also find that GP's are more willing to approve self-testing after they become comfortable with your INR knowledge. Cardio practices maintain large INR clinics and they are VERY GOOD profit centers and it's like "pulling teeth" to get them to allow self testing(my experience). For now, you may have to put up with it, but after you get a little farther along with recovery, move your INR testing to your GP. He/she sounds like they understand warfarin and their patient a lot better than the cardio and his lab people.
 

Protimenow

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You might check the Internet for Duke Clinic (at Duke University Medical Center) for a protocol for managing INR that is too low. It gives you a single dosage spike, one time, then adds a small fraction of your weekly dose each day. This was done for dangerously low INRs. There is probably a lot more online wisdom that calls for gradual increases that even out the dosing over the week. (If this was not the case, why not take the ENTIRE WEEKLY DOSE once a week?)
 

slipkid

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Happy to report that this is sorted out after a discussion there today.

What they were doing with the extra 2.5mg is not technically "wrong" for bumping up patients on 5mg a day. It is standard practice although not ideal in some people's opinions. It is done primarily to make it easier for patients (just take this extra 2.5 on one day). But they agree/understand it would be more optimal to spread the dose out more evenly, and are comfortable with me doing that, that is what we are going to do now. I am going to take an extra 1mg pill three times a week moving forward, spacing it out every other day.

This is a .5mg increase from my weekly dose from now (37.5 to 38) but I am OK with that. I tested at the low end of the range last time (2.0) so I'd rather go up slightly. We'll see how I do on this new regimen. If nec. we can adjust it again.
 

Freddie

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Glad to hear you have a understanding doctor - one that will listen to you...many don't.

So your alternating 5mg & 6mg, nothing wrong with that. And you're right, it will be easy to adjust the dosage if need be.

Although you may want to aim for your INR to be on the higher end, say 2.8. Why? Being on the higher end of your range will allow to enjoy a little more of the fresh greens that are around.

Yea done good!
 
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slipkid

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Thanks.

I guess I could have been a very anal PITA and asked to do it alternating every day including the weekends giving me different days each (following) week or whatever, or even spreading .5 around more, but we are just keeping it simple, say M6, T5, W6, Th5, F6, Sa/Sun 5. I'm open to any suggestions though. I figure MWF @6 will be easiest to remember.
 

Jamey T

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I have similar problems with my "INR clinic" and my gp. My regular doctor is in full agreement with my management of my inr and dosage, after I told him I have a vested interest in my levels. The clinic doesn't think I can handle it, but I am also one of their youngest patients, at age 50.

A lot of my information has come from people here on this site. It also just makes sense to me to take even dosages throughout the week, as opposed to "peaks and valleys" of dosages.
 

chaconne

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I don't know about others here, but it's been my experience that taking different doses some days of the week (5mg daily and 7.5mg Wednesday and Friday) doesn't lead to predictable spikes or drops in my INR. I've tested repeatedly on Sunday, when I expected a rise in my INR but can't see any correlation. Sometimes my INR is low on Sunday, sometimes it's high. My conclusion is that INR fluctuates so much (as much as 0.6 weekly for me) that I can't measure the effect of a 2.5mg up in the dose.
 

chaconne

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slipkid

BTW, I agree that 7.5mg in one day is not a good idea. My clinic would spread it around in 2.5mg doses every other day during the week.
 

pellicle

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Hi

My conclusion is that INR fluctuates so much (as much as 0.6 weekly for me) that I can't measure the effect of a 2.5mg up in the dose.
daily measurements (rather than weekly) may resolve that transient wave of INR spike more clearly. A week is a long time in metabolism and a single sample fails to provide context for the sample. For instance Olas daily measurements are here: link
 

slipkid

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pellicle;n801388 said:
Hi
daily measurements (rather than weekly) may resolve that transient wave of INR spike more clearly. A week is a long time in metabolism and a single sample fails to provide context for the sample. For instance Olas daily measurements are here: link

I agree. I wish they would test me more often, like every single day until we have a better picture of things. And have a better understanding of what day(s) are better to test to check etc.

But God help me, these people cannot even keep straight what dosage I am on, let alone have a good understanding/plan for testing & managing/adjusting dosages. I am so frustrated with this cardiologist's office. Something happened today which is at least the 4th time now that they have demonstrated either lack of knowledge in general or lack of communication within their own staff as to what is what with me.....Rant mode on....

I got a call today from someone new (to me) in the office now monitoring/managing my INR. I was tested (veinous puncture at the hospital) last Wednesday. It was the first test since I have been on the "new" regimen of Monday 6mg/Tues5/Wed6/Thurs5/Fri6/Sa5/Sun5. I thought perhaps my results might be low since it would be the first week on this new regimen and I did not have my "normal" 2.5mg Sunday bump up (7.5mg Sunday dose not taken because Monday I was starting with 6 etc). So probably I might need a full week on this new dosing to get a more realistic picture. But...let's see where I was at...they should know how to interpret the results I would think.

So today, one week after the test, I had still not heard anything back results-wise, but they called and said that I needed to get checked, I was overdue, didn't I get checked last week?? Uhhhh, I told them I WAS tested. They wanted to know where. Uhhhh, I told them at THEIR hospital. OK they had to find out what happened to those results.....

...they called me back later with the results but I unfortunately missed the call, so they left a voicemail....sigh....

"Your INR is low, only 1.7, please take an extra 2.5mg tonight, and then go continue the normal doses you are taking of 5 mg per day and 7.5mg on Sunday".

THIS PERSON, WHO IS CURRENTLY "MANAGING" MY TEST RESULTS AND DOSAGES, HAS NO KNOWLEDGE THAT MY REGIMEN HAD CHANGED.

Is this typical of other practices? I am wrong to expect my caregivers to know what medication dosages I am on etc? This is not the first time I've run into things like this there and I'm frustrated....

Rant mode off. (sorry)
 

Paul Schur

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Surgery was at a Johns Hopkins. I had the full 8"-
I'm in the process of finding a new cardiologist. I'm exactly 6 weeks out of surgery and my cardiologist's group is similar to how you describe yours. Nobody seems to know what's going on, they don't seem to care enough to take a minute out to read my file, it's always somebody new calling me, and they refuse to interact directly with my home care nurses (who have their act together) who do my INR readings, so I have to serve as a go between. My warfarin schedule, 1.5 mg on Sat, 3mg Sun and Mon, 1.5 on Tues, 3mg on Wed and Thurs, and 1.5 on Fri. I have a killer surgeon who is brilliant, and a complete waste of time cardiologist. Fortunately, cardiologists can be replaced.
 

slipkid

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Yeah Paul, I want to talk to my GP and have him do the INR/dosing, maybe even get a new cardiologist altogether as well. The cardiologist may be the greatest in the world, but I really have no idea, since I have only been able to talk to him ONCE since I got out of the hospital on May 1st. Everything goes through his maze of nurses and assistants, and miscommunication, lack of knowledge in general or of my case in particular, etc etc seem to be the way they operate. It's like they have 100x too many patients and no time to keep things straight (???). I will see what happens when/if they call me back today.....
 

marc_kowal

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slipkid;n844984 said:
Is this typical of other practices? I am wrong to expect my caregivers to know what medication dosages I am on etc? This is not the first time I've run into things like this there and I'm frustrated....

I can't speak for others, but my cardiologist's office does a very good job at managing my warfarin. I home test and call my numbers into Alere. Sometime that same day my cardiologist's office will call me and let me know if I need to make any adjustments to my daily dose. Whether I speak with the person directly or I listen to it on voice mail, they always repeat back what my doses are for each day. I think this is a good check to make sure their records are correct as well.

One other thing the office requests is that if you go on or off any meds, change diets, or feel ill, let them know as this could have an effect on your INR and how they will manage any changes if need be. I can honestly say, I have been very happy with how they operate.
 
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