Dad's INR is low again

[Jiddo]

Hi All.

My dad took his blood test today and his INR is 1.8 (range is 2-3).

Here's a brief history as of late....

8/6 - 2.0 (changed dose from 75 mg/wk to 77.5 mg since the INR was on the lower side of the range, or 3.2% increase).

8/16 - 1.9 (changed dose from 77.5 mg to 80 mg, or 3.1% increase from prior week)

8/27 - 1.8. Here is the recommendation for this week: 85 mg or 5.8% increase from prior week). The pharmacist wants to give him a super dose of 15 mg today (up from 12.5 mg) and then 12.5 mg W, Th, F & Sunday and then 10 mg T & Saturday. Next week she wants to keep the same schedule except for Monday, where she wants to reduce the 15 mg back down to 12.5, making the dose 82.5 for the week).

It's getting a bit frustrating that week over week we are increasing his dosage but the INR is getting lower. I suggested increasing the dosage to 12.5/day everyday but the pharmacist thought this was too much of a jump. She thought with the gradual increases over the last few weeks, this could end up spiking my dad's INR.

My dad did start on aspirin over the last 2 weeks or so but I'm not sure this would impact his INR.

Does anyone have any thoughts or advise?

Thanks.
Jennie

 

[Bina]

Aspirin does not affect the INR.

Your pharmacist is being very conservative in the rate of increase; especially when the INR was dropping.
I would have used a 7-10 % range of increase instead of all the little 3% increases, which are obviously not enough.

 

[Karlynn]

Your Dad is still out of range and little increases aren't doing it. I think it calls for at least a 10% increase. This pharmacist is telling you that he/she'd rather see your Dad have a stroke than experience a little inconvenient bleeding from a cut.

15 mg. isn't a super dose when the normal dose would have been 12.5.

His INR is getting lower because he's healing and his metabolism is speeding up and the increases aren't keeping pace with the increase in his metabolism.

I'm sorry this is so frustrating.

 

[ALCapshaw2]

I concur with Bina's and Karlynn's observations and comments.

Small changes are good when small changes are needed in a STABLE patient. Your Dad's metabolism is increasing as he heals and becomes more active and therefore he needs a larger increase. My *guess* is that 10% would not be too large. Those 3% increases just aren't getting the job done.

'AL Capshaw'

 

[Jiddo]

Thanks for your responses. I am going to call the pharmacist this a.m. and see if she will agree to increasing this week's dose from 80 mg last week to 87.5 mg this week for a total weekly increase of 8.6%.

The pharmacist said that in older patients, these little increases over time can accumulate and "spike" his INR in later weeks. Has anyone found this to be true?

Also, any thoughts on when to re-test? They said to come back in 10 days, but I am thinking 7 days would be better. Does it matter?

BTW - my sis has been in contact with QAS about home testing. The barrier now is that my dad's doc won't give him a prescription because he is not familiar with home testing. This is a battle we are going to have to fight...

Thx again for your help!

Jennie

 

[Bina]

Since your Dad is not in range maybe another test in 7 days is a good idea.

Home testing INR does not have to be a fight, I believe it is all in the way you "present your case".
When I wanted home testing, I called the company(mine was Coaguchek) and had them send me some pamphlets to show my doctor. I assured him I had done alot of research and we found a pharmacist in the area who would place my order and train me. (1/2 hour).

I did my first home test in conjunction with a lab draw, it was right on

 

[Ross]

Thanks for your responses. I am going to call the pharmacist this a.m. and see if she will agree to increasing this week's dose from 80 mg last week to 87.5 mg this week for a total weekly increase of 8.6%.

The pharmacist said that in older patients, these little increases over time can accumulate and "spike" his INR in later weeks. Has anyone found this to be true?

Also, any thoughts on when to re-test? They said to come back in 10 days, but I am thinking 7 days would be better. Does it matter?

BTW - my sis has been in contact with QAS about home testing. The barrier now is that my dad's doc won't give him a prescription because he is not familiar with home testing. This is a battle we are going to have to fight...

Thx again for your help!

Jennie

Jennie find a Doctor that will. This guy knows about home testing, he is just living in the past and refuses to see the light. I'm really beginning to question the labs results too.

Ask this Doctor if he's heard and/or read any of Dr. Jack Ansells thoughts or literature. If he says he's never heard of him, then you should be running from this guy.

http://archinte.ama-assn.org/cgi/co...ffda7be0f79534c578c500c7&keytype2=tf_ipsecsha

https://www.cms.hhs.gov/mcd/viewdecisionmemo.asp?id=72

 

[catwoman]

The pharmacist said that in older patients, these little increases over time can accumulate and "spike" his INR in later weeks. Has anyone found this to be true?

Will have to tell my husband about that one . He's nearly 61 1/2. He's taking 7.5 daily for a target range of 2.0-2.5 and just hit 2.0 on his last test (8/15). He's not an "active" person, but he walks a lot just because he enjoys it -- tries to do about 4.0-5.0 miles a day.

Your dad is only 62! He's still YOUNG!

The pharmacist may know pharmaceuticals, but how much experience/continuing education does she have in managing anticoagulation therapy?

 

[Jiddo]

Hi All.

Thanks for the info.

I spoke to the pharmacist this a.m. and she agreed to up this week's dose to 87.5 mg and next week he will take 12.5 mg daily with the exception of one day at 10 mg (for a total of 85 mg). I am hoping this will get him in range.

I just told the pharmacist the new recommendation didn't sit well with me and that I would rather my dad be at the higher end of the range. She seemed more willing about giving in to the extra dosage today than when I originally spoke to her yesterday.

Ross, QAS is going to call my dad's doc and discuss home testing. I'll forward the info you provided to my sis to make a case. I am hoping to get my dad to switch over to my medical provider as they encourage home testing. This will have to wait until Jan, when my dad is able to change his insurance.

Thanks again for all your responses. I'll keep you posted of the results next week.

Jennie

 

[Karlynn]

I don't know why she's lowering next week's dose. Will he be testing before going to that dose?

Is there some other place that you can talk to about managing his warfarin?

 

[PeggyM]

I know this is not advisable and certainly not recommended, but there have been a few times when I did not agree with the Kaiser pharmacists (or whatever they are) who manage my INR. They too are very conservative. So I have increased my dosage myself a few times to get back in range. And yes, it worked. Sooner rather than later.

 

[ALCapshaw2]

I know this is not advisable and certainly not recommended, but there have been a few times when I did not agree with the Kaiser pharmacists (or whatever they are) who manage my INR. They too are very conservative. So I have increased my dosage myself a few times to get back in range. And yes, it worked. Sooner rather than later.

Did you tell them that the reason you were back in range was because YOU increased your dose above their recommendation? If so, what was their reaction?

'AL Capshaw'

 

[PeggyM]

Yes I did. And their response was nada. Like "ok bye bye". I think one of the times the girl said "Oh you really shouldn't do that." But that was was it. They are mostly robotic and don't pay attention. The still don't remember I take my coumadin in the mornings and always leave night instructions and forget I'm on lovenox still. I don't trust them.

 

[PeggyM]

Jiddo, I just looked at some previous posts and see your Dad is with Kaiser too. So we're both dealing with feelings of not trusting their coumadin management.

We could complain. But then they put a little sticker on your chart that means, "Look out! Trouble!" lol.

 

[Ross]

I've done what Peggy mentioned, also. Jiddo, personally I would be inclined to leave dad's dose at 87.5mg weekly, not decrease it the next week, and see what the results are. You can either fess up that you did it deliberately, or you can just claim you thought that's what was agreed on. I would probably do the latter. I doubt you will get much of a reaction from the pharmacist, either way. There is less than a 3% difference between a weekly dose of 85mg and a weekly dose of 87.5mg. It's not that big a deal, by any objective standards. In terms of the "social" implications of taking the bit in your teeth, professionals deal with people every day who don't even take their coumadin or who have no idea what dose they are on. I don't think it's going to get a big rise from her for you to be "confused" over a minor point like decreasing his total dose by 2.5mg next week. They shouldn't give complicated instructions like that, anyway.

I'm sorry you and your parents are going through this kind of stress. On one level, it's totally unneccessary. On another level, there's really nothing you can do about it. I'm just sorry.

Ultimately Kaiser will screw around long enough to provoke them into taking matters into their own hands and then it will all become plain as day what should've been done to start with.

 

[Jiddo]

Hi All.

Thank you for your encouragement and advise. I had the same thoughts about keeping my dad on 87.5 mg for week 2. However, I wasn't as concerned about this week because he is going to re-test on 9/6, which is mid-way into week 2. Everyday leading up to the re-test he will be taking 12.5 mg. If his INR is stable at the re-test, I will push to keep him on 87.5 mg for the week or 12.5 mg/day. This will be easy for my dad to remember. Now it's confusing because the doses change so often.

Peggy, thanks for your thoughts on Kaiser. Believe me, I think one of those "notes" already exist in his file. I call them on the day my dad takes his blood tests and sometimes multiple times a day to get the results. I don't care what they think at this point because my dad's life is more important that their perception of me at times.

My dad has an opportunity to change his insurance in Novmber for a January start date. I am scheduling a consultation with my clinic, which I have had very positive experiences with. Peggy, have you heard of the Palo Alto Medical Foundation? I'm not sure where you live but they have a coumadin clinic in Fremont and they do the finger prick test and give you results on the same day. I attended their coumadin clinic and was very impressed with the presentation. They also encourage home testing.

Anyways, I just hope we can get my dad in range soon. I'll keep you posted on the outcome.

Thanks again for your encouragement.

Jennie

 

[Karlynn]

Jennie, a thought occurred to me (how rare!!! ). The pharmacist is so concerned that your Dad's INR will spike if she raises his dose too much, so she's been keeping it very low - in the 3% range. But he's had enough tests, that aren't spiking, to prove that A.) the % she's increasing aren't enough to even raise the INR to range and thus B.) not making him spike.

So one could ask - why is she still dosing with this fear of spiking? Tell her that her main concern needs to be getting him in range, she's already proved he's not going to spike with practical (and GUIDELINE) dosage changes by using lower than is prescribed by those that know something about dosing. (Which isn't her )

 

[Jiddo]

Hi Karlynn.

That is a logical thought that didn't come to mind. Thanks for bringing this up. The pharmacist has not paid close attention to how my dad has been reacting to the coumadin. Back in late July, he was at 1.7 and we increased his dose from 75 mg to 82.5 mg (9% increase, due to my urging) and the following week he was at 2.7. Then we ended up reducing his dose back to 75 mg and he fell down to 2.0. Thinking back, we should have probably kept him at 82.5 mg back then, which would have probably resulted in a more stable INR.

Jennie

 

[catwoman]

Jennie:

Last night I told my husband about this thread and told him we could have been facing this same situation. Our PCP's office is "managing" John's INR, or at least is doing his tests. I've had to override their recommended dosage changes because they were too low. (Our PCP is off on Wednesday afternoons, which is the only time INR tests are run there.)

Two weeks ago, John's INR was 2.0. Yesterday, it was 2.4. If it's in range on 9/12, he can go to testing monthly instead of every 2 weeks.

If we had left everything to the practice's dosing schedule, we'd be up a creek.

I've used Al Lodwick's algorithm chart for almost 4 years, and it's been a godsend. My husband is very appreciative of my running interference on his INR.

Hope you can achieve this for your dad.

 

[Ross]

Hi Karlynn.

That is a logical thought that didn't come to mind. Thanks for bringing this up. The pharmacist has not paid close attention to how my dad has been reacting to the coumadin. Back in late July, he was at 1.7 and we increased his dose from 75 mg to 82.5 mg (9% increase, due to my urging) and the following week he was at 2.7. Then we ended up reducing his dose back to 75 mg and he fell down to 2.0. Thinking back, we should have probably kept him at 82.5 mg back then, which would have probably resulted in a more stable INR.

Jennie

Or even better, the correct dose.