Coumadin Dosing Strategy - Question for Mr. Lodwick

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Gary Snodgrass

I have a question concerning the dosing strategy which my doctor recommended to bring my INR in range. My daily dose of coumadin is now 5mg which resulted in an INR of 2.27. My doctor would like the INR to be in the range of 2.5-3.0. A previous attempt to raise my INR by going to 6mg a day resulted in an INR of 3.53 and blood in the urine. This time my doctor had me take an extra 2.5 mg for two days. I don't yet know the result as I haven't had my blood drawn this week. This strategy doesn't make any sense to me. It would seem to me that putting an extra 5mg of Coumadin into my system in such a short time frame will result in another high INR with potential bleeding. I thought it would make more sense to take 6mg, 3 days a week and 5mg, 4 days a week. Can you please comment. I am getting the feeling that my doctor is not skilled in Coumadin dosing and would like an expert opinion. Thank you. :confused:
 
I often have periods of time when 5 mg is not enough and 6 mg is too much. I've done the alternating doses just as you described with great success. I can't comment on the extra 2.5 mg on two consecutive days. I've found that gradual adjustments over several days works best.
 
My dosage is also 5 mg per day, but with the increased activity in summer, my INR has been 2.0 for several weeks. So my dosage is increased each week. I have 3mg, 4mg, and 5mg tablets, so I can mix to get the right dosage. When my last test was 2.0 (way too low), I took 7mg the day of the test, then 5mg, and then 7mg again, in hopes of bringing it up to a reasonable range. I'll continue taking 5mg until my next test on Friday. Since it takes around 3 days for the coumadin to take effect, I hope to have a much better reading this Friday.
I go to a Coumadin clinic at the local hospital which has one of the machines to test a drop of blood -- much better than filling a test tube. Ask if you can find such a clinic nearby. I have had doctors in the past who didn't know what they were doing with coumadin dosing; I started figuring out my own dosage a couple of weeks after surgery. The nurse who runs the coumadin clinic I go to now is very good at gradual adjustments of the dosages.
 
Different doctors seem to have different ways of adjusting dosages. When we were dealing with a cardiologist who has 11 partners, it seemed that there were at least 12 ways of doing it. When we changed doctors, I asked, "Why can't the dose be the same each day?" If 5 isn't enough and 6 is too much, how about 5-1/2? After much talking about this is the way we do things, etc. I still didn't have an answer to my question. Finally, the doctor said it had alot to do with the dosages that coumadin comes in. Getting to the bottom line, I changed my question to..."Is there any reason why we couldn't take the same dosage everyday?"
That was nearly a year ago. Since then my husband has been been very successful in taking the same dose every day. When changes are needed, they are increased or decreased by 0.5 (1/2). I really do believe that the doctor was willing to do this because we have a monitor and can test weekly, or more often if we choose.
 
My husband has been on Coumadin for 25 years. Here's what I know from his experiences. Your body metabolizes Coumadin according to what you eat, what you drink, how much exercise you get, how much stress your body is under healthwise, what medicines you are taking, what over-the-counter stuff you're taking for a cold, allergies, etc., what vitamins you're taking, whether you had a spat with someone, drinking different water on vacation, flying on an airplane, the phases of the moon, sunspots and dust storms on Mars. It could even have something to do with what sign you were born under.

Just a little joking, but I'm probably not far off the mark. The body's metabolism of Coumadin is tied to so many things in your day to day living, that it would be impossible to try to figure out how to keep it from changing. In addition, it takes three days from the time you make an adjustment to have it register in your INR.

If there were a good way to keep it from changing frequently, my husband would have been able to figure it out, but he's given up on that. He doesn't even worry about it any more. That's the doctor's job. He goes and gets it tested, he takes what they tell him and then forgets about it until the next test is scheduled.

He has good people figuring out his dosages and is rarely out of range. He's had people in the past that didn't know how to do it very well, and it was "yinging and yanging" all over the place. They are no longer with us. It takes a steady hand on the tiller, little steps at a time, no wide swings.
 
With regards to Coumadin dosing, you can remain fairly stable for a long period of time and then suddently swing one way or the other. Its normal for the INR to change that way.

I would not make too large a dosage change at any one time (unless you were drastically high or low) - rather, small incremental changes work best - especially given the 2-3 day lag on Coumadin's affect on the blood INR. Home testing is a real plus since you can monitor where your INR is trending and adjust as needed. I usually test Sunday and Wednesday when I'm making changes. Once stabilized, I'll go back to once a week testing.

By the way, I've got 4, 5, and 6 mg pills and by splitting them, you can basically hit most dosage levels from 2mgs up to 12 mgs - including quite a few of the intervening 1/2 mg. dosages.
 
I agree with Nancy that determining Coumadin dosages is more of an art rather than an exact science. It seemed like a real trial and error effort for the first couple of months after my surgery.
Once I got into a normal routine I took 5.0 mg per day and 2.5 mg on Saturdays for a year and my INR was rock-solid between 2.6 & 2.7. This included a couple of business trips to Europe with jet-lag, different food, etc.
So then I drive to Michigan on vacation and it dips to 2.2! Go figure...
I do think that one of the things that helps me personally is that I am very consistent in my lifestyle (which my kids classify as dull & boring). I exercise a lot, but on a very set weekly routine. I also try to follow a very rigid diet. The one area I indulge myself is that I'll have a couple of glasses of red wine with dinner three or four nights per week.
 
What if the sign you were born under was, "St. Jospeh's Hospital"?

Basically all of the information is correct. Warfarin management is much more of an art than a science. You have to find what works for you.

To find if there is an anticoagulation clinic near you look at www.acforum.org and click on clinic locations .
 
The 10% solution!

The 10% solution!

At the meeting in DC ( where I met Al) I was at lunch sitting with a hematologist from Vienna ( Austria not Virginia) and the topic of warfarin dose adjustment came up. I told him I was being managed by 10 cardiologists and 5 nurses and if I was lucky enough to get a call from their office I was totally confused by the dosing changes.I asked him if he could recommend a good software program. His advice- as a mitral my Rx INR range is 2.5 to 3.5......if I go under 2.5 raise weekly dose 10% .....if over 3.5 decrease weekly dose 10%. Works for me!
 
I had not thought of it in that way - as a percentage change - but you are right, the 10% solution has also worked for me. You just have to give the change time to work through your system and stabilize at the new level.
 
coumadin dosing strategy

coumadin dosing strategy

Hi Gary,
After 5 years of coumadin I am now on 6 1/4 mg 5x a wk and 7 1/2 mg 2x a week. It seems to work well for me to keep me in the 2.5-3.5 range. As I'm sure you know If you lose any weight, or exercise more, you'll have to adjust it. Have you been doing more things lately? Like everyone has told you it is just a bit of fine tuning - if it's higher eat a bit more greens - have your inr checked a week later to see if that helped. If it's too low add a little extra coumadin a couple of days throughout the week and have your inr checked a week later. I've found that if you add too much or take away too much you can do too much spiraling. I'm a Rochesterian too. Where did you have your surgery?
Sharon
 
Hi Al-

Nice to see your posts again. Regarding your question about what happens if you're born under a hospital sign.

It means that during your lifetime you will be involved in the medical profession in an intense way, either as a patient or as a professional. And if one of the moons is rising, you get to have a lot of shots. :p
 
I don't get too many e-mails that make me laugh, but Nancy's reply did. In fact I had to go upstairs and tell my wife and she laughed too.
 
Coumadin and Vitamin C

Coumadin and Vitamin C

I went to Al's page on coumadin drug interactions and noticed that the there was no link for Vitamin C. There were links for E & D and (of course) K. I have read that C will affect the INR (lower) but at what dosage?

Thanks,
Greg T
 
The reason that there is no information si because I can find nothing other than some listings saying that vitamin C might affect the INR. There is no dosage information available and I can find nothing in medical journals about someone actually suffering harm from this. So I have disregarded it. I have seen doses up t0 1500 mg per day with no harm. I suppose there might be something happen if you got up to around 24,000 mg per day like they used to advocate for colds, but there is no hard information.
 
Coumadin and Vit. C

Coumadin and Vit. C

Thanks Al:

In the hospital I was getting 500mg. Prior to that I was up to 6000mg. I am still taking 500mg but plan to increase that to 2000mg/day. Home testing is going to be a big help with this.

Greg T
 
I am very interested in what you learn about the INR when you increase the dose of vitamin C. If you could keep a diary of warfarin doses, vitamin C doses, INR and anything else that might affect your warfarin it would be helpful. Whether the INR changes or not will be valuable information. I would publish this on my website with or without your name as you choose.
 
Ok Al:

I am not very good at keeping records. I will give it a try. I hope the resulting info will prove to be useful.

Greg T
 
Al,

I noticed no change in my INR when adding the C supplementation, which was 250mg per day. Though I did have a concern with B6, shot up to a 7!
 
Hi Al,

I take 1000 mg of C,(500 in morning, 500 in eveining), 400 IU of E, and a Centrum multivitimin along with 5mg od Coumadin, a 50 mg Atenolol, and a 325 mg coated Aspirin on a daily basis.

My INR usually stays between 2.0 and 2.5 which is my recommend target range. This range is recommend for 2 main reasons, I am taking Aspirin with Coumadin, and also because my mechanical valve is for the Aorta which has a more forceful blood flow than the other valves, and therefore, less opportunity for clotting to form. These are my doctors comments. So far, 2 + years post op, I have not had any problems of any significance, and my INR has been very stable.

I also noticed that when I do party too strongly, (weekends at the lake on the boat), my INR is not greatly effected. For example My INR on Thurs was 2.3 when I returned from the lake on Sunday it was 2.4. It seems alcohol,(beer), does not really effect me much. I wonder if it is due to the vitimins?

Rob
 
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