Inr

[bigsidster]

Hello

My INR dropped from 2.3 to 1.9 from a Tuesday draw to a Thursday draw.My doc wanted me to continue on 5mg coumadin.I went to 6mg on Friday and doc called and wanted me to go to 6mg on Monday,but I was ahead of her.I next tested at 2.4 on 6mg and doc kept dose at 6mg but the office is closed until dec 29.I think if I stay at 6mg i will be up in the 3 something by then.I am taking 5mg until the 29th,what do you think?I also think that it may be the docs practice to have receptionist tell patient to continue same dose until doc has time to review charts.

 

[Bina]

howdy, can you organize your data a bit for me?
Date....dose.....INR
Date....dose.....INR
Date.....dose....INR
You may need to alternate 5 mg and 6 mg until your next test, drastic changes are no use when a nudge is needed.

 

[bigsidster]

Bina

Dec 17 Inr reported as 1.9---down from 2.3
DEC 18 5MG
DEC 19 6MG
DEC 19 6MG
DEC 20 6MG
DEC 21 6MG
DEC 22 TEST INR 2.4 --6MG
DEC 23 5MG
DEC 24 5MG
DEC 25 5MG
NOW HAVE TO WAIT UNTIL DEC 29 FOR LAST INR REPORT FROM DEC 24
DOC WANTED ME AT 6MG SINCE DEC 22

 

[ALCapshaw2]

I *assume* that your target range is 2.0 to 3.0
I also *assume* that you were taking 5 mg/day prior to Dec 19

The full effect of the 6 mg doses are probably just showing up now
BUT dropping back to 5 mg will lower that by Dec 29 if you continue to take only 5 mg.

Your Doc's recommendation to take 6 mg until Dec 29 is at the high end of AL Lodwick's dosing guideline.
Alternating 5 and 6 mg every other day would have been a good compromise.
It 'probably' wouldn't hurt to return to 6 mg for the next 4 days which will average out to 5.5 by early January. Too bad you can't test on Monday Dec 27 and then decide where to go from there.
You will still need to test again after another 4 to 7 days.

Going 4 days at one dose and then another 4 days at another dose will make your INR move around more than I would like and will make it more difficut for your anticoagulation manager to predict where you will 'settle out' and more difficult for them to recommend your next dosing schedule. Alternating daily with a small change gives a smoother result.

'AL Capshaw'

 

[catwoman]

Bigsidster:
I agree with Al on alternating your dosages.

You're only 1 month post-op, so your INR is apt to drop as you resume your normal activities and eating habits. Expect to see some blips up and down in your INR until your activity level is stable -- usually 2-3 months post-op, but it may vary depending on other meds, etc., you're taking.

 

[Bina]

Bina

Dec 17 Inr reported as 1.9---down from 2.3
DEC 18 5MG
DEC 19 6MG
DEC 19 6MG
DEC 20 6MG
DEC 21 6MG
DEC 22 TEST INR 2.4 --6MG
DEC 23 5MG
DEC 24 5MG
DEC 25 5MG
NOW HAVE TO WAIT UNTIL DEC 29 FOR LAST INR REPORT FROM DEC 24
DOC WANTED ME AT 6MG SINCE DEC 22

thanks for listing the data.....and I will stick with my earlier prediction of alternating 5 mg and 6 mg until you
get a new INR reading.

 

[Protimenow]

It sounds like the advice you've gotten has been pretty good. One thought -- if you continue on 6 until the 29th, you may still be in range. If you are at the high end, it may be easy to get back down with slight dosage adjustments, and more greens in your diet.

I'm concerned that if your doctor thinks you are ignoring his (or her) dosing advice, you may have problems getting this doctor to let you do self-testing or self-management. As long as your INR doesn't jump or start to yoyo, it may best, for now, to follow the doctor's recommendations -- at least, for the next four days. (I guess, too, you can go back to a different dosing schedule - but you may not want to be totally honest about changes you've made).

It would certainly be helpful if you had a meter - or could find a clinic that uses a meter for instant (well, within five minute) INR results. Having to wait DAYS for test results doesn't make it particularly easy to manage INR because any change would be a response to what was read DAYS ago and may not be representative of what you've done in the last few days to change it.

(Others here know that I'm an advocate for self-testing for anyone who is able to do the test and who is on chronic, long-term warfarin)

 

[bigsidster]

I agree with everyone here saying to alternate between 5 and 6 mg until next report.I was asking just to confirm my thoughts on it.Thanks for your input.I will be looking into getting a self testing meter because we do a lot of motorhome travel in the US and we live in Canada.Yes my range is 2.0 to 3.0 INR and I was at 2.3 on 5mg and then ate kiwi and cantelope 2 nights in a row and think this is what put me back to 1.9.Then doc had me on 6mg that got me back to 2.4 in 4 days and I alternated 5 and 6 mg because I supected it was the kiwi and cantelope.When I went to 2.4 so fast i figured I should alternate 5 and 6 mg or cut back to 5mg or next reading would be in the 3 something range.I am alternating 5 and 6 until next reading and will let you know.

ps---anyone have the AL LUDWIG CHART---THAT COULD SEND ME A COPY?

 

[Freddie]

I have a copy and can send it to you since I use the following site more often than the chart - check it out:
http://www.pace-med-apps.com/CoumCalc.htm

Just fill in these blanks:
Continued Dosing:
Target INR: Current INR:
Week/Day Current Dose:

Send me a PM and I'll send out the chart ASAP

 

[ALCapshaw2]

I have a copy and can send it to you since I use the following site more often than the chart - check it out:
http://www.pace-med-apps.com/CoumCalc.htm

Just fill in these blanks:
Continued Dosing:
Target INR: Current INR:
Week/Day Current Dose:

That's a Very Good Calculator Site.
Note that if you use 2 different pill sizes (doses) you can just skip the first line
and go the the second line, inserting your WEEKLY dose and it will give you a Weekly Range
which you can figure out how to reach by alternating your available pill sizes.

'AL Capshaw'

 

[normofthenorth]

My situation is somewhat similar. When I left the Hospital, I was just creeping up to my range (2.5-3.0), with 2.1 as my final Hospital reading. I was taking different amounts almost every day in the Hospital, and my adjustments afterwards were pretty oblivious to the slow "feedback" (multi-day time-lag) between changes in dosage and changes in INR. Here are my numbers as I know them:

Date INR Dose Comments
Dec. (mg)

2 1.16 5 1 d post-op
3 1.41 5
4 2.23 3
5 1.79 5 rec'd 2mg Vit. K "PO" for pacer wire removal to depress 2.23 INR. (Extended my hosp. stay 1 d!)
6 1.41 7.5 comment field on Dec. 6+7 shows an "<--->" arrow, as if the results were entered backwards(?)
7 2.17 4 ditto -- but the INR results for 6th and 7th are NOT backwards.
8 --- 6
9 3.1 5
10 --- 4 MD said to do 5. I figured if 5 took me from 2.17 to 3.1, it was prob too high, so I tried 4 instead.
11 --- 4
12 --- 4
13 --- 4
14 2.8 4 MD said "So 5 looks good!" I said, actually it'd been 4, but yes it looks good(!).
15 --- 4
. . .
21 --- 4
22 1.8 6 In ER, trying to catch up to 2.5-3.0 range. Nobody told me squat, I was improvising.
23 --- 5
24 --- 5
25 --- 5
26 --- 5
27 --- 5
28 --- 5
29 --- 5 Next chance to test
30 --- Get results from next test, and see GP (the one who's filling in for my own)

Any comments are welcome.

Based on the Online Coumadin Dosing Calculator, my reaction to the 1.8 was excessive, and I may be oscillating around a good INR, like a roller coaster.

BTW, I can't figure out how to make the display use fixed fonts (like Courier) rather than proportional ones. The latter makes empty columns "collapse", which is a nuisance. After Al C's suggestion, I've replaced the empty column (no INR reading) with "---". (Thanks, Al!) I hope everybody can figure out the columns.

 

[Herb M]

You should not have to wait several days to get the INR results. I go to a hospital lab for my draws. I sign a brief release so the results can be given to me. They also sent the results to my doctor.

I have learned that the doctor's office may wait a few days to give me the results. I self adjust my doseage. Sometimes the recommendations I get from the doctor is not acceptable to me.

 

[ALCapshaw2]

Norm -

You need to receive your INR test results No Later Than the Next Day (and preferably the SAME day).
You also need to understand that it takes 3 or 4 days for each dose to become fully metabolized so testing and especially changing doses before 4 days typically results in an Unstable INR.

And YES, Over Dosing followed by Under Dosing (or vice versa) leads
to the the wellknown "Roller Coaster Effect".

You also need to know that maintaining an INR within a range only 0.5 wide is Very Difficult and maybe next to impossible.
This is in large part due to the fact that there is small but non-zero measurement tolerance and your INR does change with metabolism,
especially when you are first beginning anticoagulation after surgery (or other invasive procedures).

(try using a filler such as 0 or (.) for empty columns).

'AL Capshaw'

 

[normofthenorth]

Herb and Al, my MD and I generally get my INR results in around 12 hours. She gets them directly then phones me with the number and a dose recommendation, is how it's worked. But it's only worked maybe ONCE, because I caught a cold and stayed home for a week, AND I took the trip to the ER (and got my INR tested), AND the lab and the med. clinic both closed from Friday noon until Wednesday, for Christmas. If it were up to me, I'd always get the results instantly, and I'd also probably get tested today. But no. (But then, if it were up to me, there wouldn't be a multi-day time lag between dose changes and INR changes -- and wait, I probably wouldn't even BE on Coumadin!! )

Al, those comments are very helpful. I hadn't realized how "tight" my 2.5-3.0 INR target was. That also explains why the online calculator won't even let me SET a target zone that tight!

 

[tommy]

Waiting 5 days defeats the effectiveness of the process (as you are experiencing). Why bother?

I also think that it may be the docs practice to have receptionist tell patient to continue same dose until doc has time to review charts. .

I hope that's not the case. We need to have confidence that our results and ensuing instructions are well-vetted and personalized to our situation. Protocols and standards are fine, but transitions (surgery, illness) require more thought.

 

[ALCapshaw2]

All too SLOWLY, more and more anticoagulation managers are switching to Finger Stick Testers that give the INR result in a Few Minutes vs. Lab Draws. My Very Large Coumadin Clinic (3000 patients) uses Finger Test Instruments. Anytime a reading comes back at 4.5 or higher, they automatically do a vein draw which is sent to the main hospital lab (in the next block) by Vacuum Tubes similar to those used by banks for their drive-in service. Results from the Lab are usually received within 2 hours.

Home Testers using Finger Stick instruments avoid all of those delays and the inconvenience of having to drive to the clinic. The Downside is that it is necessary to find a Doctor who is willing to 'supervise' your INR management and receive the INR result call or fax from the meter provider. Will anticoagulation patients ever be trusted to manage their own INR in a manner similar to diabetics? I'm thinking not in the near future :-(

'AL Capshaw'

 

[Protimenow]

I agree with everyone here saying to alternate between 5 and 6 mg until next report.I was asking just to confirm my thoughts on it.Thanks for your input.I will be looking into getting a self testing meter because we do a lot of motorhome travel in the US and we live in Canada.Yes my range is 2.0 to 3.0 INR and I was at 2.3 on 5mg and then ate kiwi and cantelope 2 nights in a row and think this is what put me back to 1.9.Then doc had me on 6mg that got me back to 2.4 in 4 days and I alternated 5 and 6 mg because I supected it was the kiwi and cantelope.When I went to 2.4 so fast i figured I should alternate 5 and 6 mg or cut back to 5mg or next reading would be in the 3 something range.I am alternating 5 and 6 until next reading and will let you know.

ps---anyone have the AL LUDWIG CHART---THAT COULD SEND ME A COPY?

You can't go to 2.4 'so fast.' It takes a few days to get results from warfarin - the jump may have been a result of your dosage a couple days before your 2.4. I'm not sure about Kiwi or Cantaloupe having an effect on INR - does anyone else know?

Having your own meter is truly empowering - I've made the argument many times, so I won't push it this time (some people seem to get offended by my frequent mentions of my position on self testing).

 

[Protimenow]

Al mentioned self-testing and then calling your meter provider, who will contact your doctor. This is the Alere and Philips system.

However, not everyone has to go through these providers. It may be possible to find a doctor enlightened enough to let you manage your dosing (with regular reporting to the doctor of your INR and dosing history), or who will let you self-test then call the results directly to the doctor for advice on dosing. My impression is that many on this forum use their own meters, and don't have to go through Alere or Philips. They either self-manage or report to their doctors for dosing instructions.

Of course, not everyone is capable of self-testing, and not everyone is capable of self-management. In most cases, the doctor will assess each patient's ability to do one or both, and decide whether self-testing is a reasonable approach to anticoagulation management.