Coumadin Dosing Strategy - Question for Mr. Lodwick

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This is like many other things and warfarin - as long as you do not change the vitamins there is little effect on the INR. Running out of Centrum is one of the biggest problems I see in my patients. They are retired (mostly) and if they run out and it is several days until the SS check comes they have no money for more vitamins and their INR goes up and they get bloody noses.

Gina - I've never seen a problem with vitamin C under about 1000 mg/day. Neither has anyone ever told me about B6 and an elevated INR before. I'll keep it in mind.
 
coumadin dosage

coumadin dosage

I check my INR at home and work with a clinic as to dosage changes. The clinic's view agrees with Marty's - 10% more or 10% less. I have had some success with this and it is easy to figure out. Arlene
 
As different as night and day...

As different as night and day...

I have noticed on two occasions that my INR is lower in the morning(1.9) than in the evening(2.7). Could this be due to my consumtion of vitamin E (800 IU) in the morning? My guess is that by the time the E is fully digested(toward the evening) it's anti-coag effects would be visible in an evening INR check. Has anyone noticed this? I read the article on E on Al's site but this effect was not mentioned. Given all the numerous factors affecting the INR, this might just be a coincidence with something else.

Thanks,
Greg T
 
The latest thinking about vitamin E is that it affects the platelets. This would cause bleeding but not have any effect on the INR. But the thinking could change.

If you get a 0.8 unit swing in one day, the most obvious answer is that the testing unit is defective. I got a new CoaguChek last month and it gave two readings that did not correlate by 0.5 units on 2 of 10 readings with the old CoaguChek. Roche replaced it immediately. It does not have to be off every time.

Unless you are a very rapid metabolizer of warfarin (taking more than 20 mg per day), I am sure that this is not due to changes in your blood. The reason is that the vitamin K dependent clotting factors in your blood are only turned over about every three days. The warfarin has no effect on the clotting factors that are already circulating. So an 0.8 swing in less than 24 hours is almost a physical impossibility.

Another possibility is that you had water or alcohol on your finger that was not completely dried off when you did the test. This will cause the INR to be high.

It is 99.9999999% likely that it is something other than your blood causing the strange fluctuations.
 
Thanks, Al

Thanks, Al

I will be calling QAS tomorrow!! A recent delivery of supplies arrived almost hot to touch. QAS advised me that it should not matter :eek: The bags of "ice" were hot and so was the box that the cuvettes were in! Has anyone else ever recieved supplies in this condition ?

Greg T
 
Vitamin E

Vitamin E

Funny, Was just talking to a friend at the pool today who asked me if I remember her husband having to go by ambulance to hopital last year..She told me it was because his doctor did not tell him not to take Vit. E...He takes Coumadin and has been doing so for 4 years. Yet, she told me today he only checks it INR level every 4 months..The day the ambulance was called, he fainted with a very serious nosebleed...I tried to educate her a little about his needing to check it more often (INR) but she was not worried..said his Doctor never mentions it..I'll know now if I hear or see the ambulance at their house again..but she did say, he will never take Vit. E again
 
Mine was warm too

Mine was warm too

I looked all day for my first shipment...finally called QAS..They said it was on truck...at 6 p.m. they came up driveway..making the shipment late 3rd day..When we opened the box the freezie things were melted. Called right away .and forgot who answered but said they would be fine. Been using them ever since..I'm going to remember that about water or alcohol on finger because my last 2 weeks have been high 3.8..I may not be drying my finger good enough. Even ate soon cold slaw..but didn't change.Or is it a full moon outside.:D Bonnie
 
Hi Bonny!

Hi Bonny!

According to my wife, who got home before I did and who opened the package first, the "freezie things" were not only melted but very hot to the touch. The outside temperature was in the upper nineties that day. The box that the cuvettes came in was also very hot. I know that these things are fairly durable, I don't think they could have survived that much heat. (90+).

About the vitamin E. I was given vitamin E in the hospital. I remember thinking "cool I take these at home!". Neither my surgeon or his staff ever said anything about vitamin E. Either has my cardiologist.

4 months seems way to long between tests. I prefer once a week or maybe even every two weeks.
 
Hot to the touch probably damaged the thromboplastin.

Four months between tests would be indefensible in a lawsuit.
 
Vitamin E

Vitamin E

Hey Greg,

I subscribe to Dr. Andrew Weil's newsletters and remember reading that Vitamin E is best taken with the noon meal (along with Selenium). Weil indicates it is absorbed better with some fat intake.

http://www.drweil.com

As an alternative to cramming all my meds and supplements down just at breakfast and dinner, I switched to this regimen about 6 months ago and my INR's have been fairly stable. I feel pretty good so something's working right!

Regards,
 
Al: That is what I thought (damaged the thromboplastin) so I called QAS. They seemed to think that excessive heat for a short time would not be a problem. :confused:

Perry: What regimen would that be?
 
Greg:
Funny you should mention that!!!! We received supplies from QAS yesterday, and I have been stewing about them for the last 23 hours. The package had four of the ice bags and all were at room temperature, as were the supplies. I asked for extra ice bags becuse we live in Tempe, Arizona where the temperatures run between l04degrees and 115 degrees all summer long. The delivery person handed me the box, so it was not sitting about my place for any time at all.

This same thing happened with our last supply which was received the first week of April. I called QAS and they gave me the same response you got. Al used all the supplies and didn't seem to have any problems. Still, this give one great pause. I wonder if the ice bags were solidly frozen when the supplies were packed. In past we have received supplies from QAS and from the company, International Technydine, and there were ice crystals present in the bags. I'm going to test this by solidly freezing the ice bags and placing them in the ice chest and box. We'll see what happens after two days. I'm also going to call QAS.
Regards,
Blanche

Should we post this on the ProTime/QAS site here?
 
Testing often for INR

Testing often for INR

I tried again to talk to my friend at the pool today about her husband testing every 4 months while on Coumadin. She said their Doctor, a woman, not knocking women doctors, in a small town near where we live here in the mountains put him on the Coumadin 4 years ago when they moved here from Florida. Reason, was a lazy ???in the heart???:confused: And that was the only problem he has ever had..and I said, Do you realize what Coumadin is (type drug) and she said Blood thinner..and told me that I was dwelling(southern expression) too much on it..End of conversation....Makes me wonder now if it was really the Vitamin E that she thinks made him have the severe nosebleed. My cute little clinical nurse from Cardiogist's office called and told me....stay on same doseage and eat lots of salads this weekend..Mine has been 3.8 for 2 weeks..What was even cuter..she said and don't call me for a few weeks...She knows I have my new toy (Protime) and I must be calling her too much..:D Bonnie
 
Hi Blanche,

I live in Tucson and when I receive my supplies it never is frozen anymore either. I've always been here when they deliver so it gets put in the fridge at once and I've never had a problem.
Yeah, I do get an error message sometimes, but I don't think it has anything to do with that.
Happy Protiming!


Christina
AVR's 8/7/00 & 8/18/00
TMC, Tucson. AZ
Dr. Gulshan Sethi
Mechanical
 
Protime error

Protime error

Hubby does my machine while I prep finger and once we got machine error and John called QAS and they will give you a free cuvette if it says Machine error. Worth the toll free call to tell them. Bonnie
 
I think that it you had stuff that was hot to the touch and a problem, then, "shouldn't be a problem" is not the answer. It is a problem. Ask the person how they know this shouldn't be a problem.
 
Coumadin

Coumadin

I Have hade so much trouble with my PT since surgery in 3/02
RIght now I am going to the Dr. ever day to get it tested since I got off of the hosp. last sun. Right now it is a good as it has been in a long time 2.9. They have me on 5mg. on tues. wed. fri. sat. mom. and 4mg. the rest of the week, Repeat pt on next tues.
I have been so fatique, I sleep today for fours. that just not me.
Thanks for lisitening,
SHerrin Hutt
 
Hi Sherrin-

Your INR looks pretty good right now. There must be some other reason that you're so fatigued, You should ask your doctor or cardiologist to check you out. There could be lots of things that could cause that.

Take care of yourself and let us know what happens.
 
Please everyone remember --THE DOSE OF WARFARIN IS NOT IMPORTANT. ONLY THE INR MATTERS.

Sherrin - the fact that your doctor is testing you every day shows that (s)he does not know how warfarin works. It takes about 3 days to see the full effect of a dosage change. When you test and change the dose every day the dose will NEVER stabilize. You have to look at what the dose was for the past 7 days, then make any changes from that and then try it for a week and see what happens.

I've tested over 1,500 people (15,000 tests in the past 5 years) and I can guarantee you that testing every day is just like a puppy chasing its tail.

You need a referral to someone who understands warfarin dosing.
 
To DaveCV67,

I am taking 22mg Coumadin every day now. Maybe it is the humidity in AZ that we struggle with in July and August. Before July & August I was taking 20mg Coumadin every day for a long time.
INR was 3.8 this past Tuesday.
Last week Friday it was 2.9.
I stay within range, and my doctor is happy. He doesn't mind the INR to be a bit higher.
I self test and am feeling good.

To Al Lodwick...
I hope I have a good liver, and do worry about the amount of Coumadin it takes for me to stay within range. Do you encounter many patients that are taking as much or more Coumadin than I take?
Please advise!

Christina
AVR's 8/7/00 & 8/18/00
Tucson Medical Center, Tucson. AZ
St. Jude's Mechanical
Dr. Gulshan Sethi
 
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