Question for home INR testers

[Jason]

I have been bouncing around a bit with my INR due to changes in exercise and travel, and have been testing and changing doses per the INR clinic. The INR clinic I am near seems to follow the Online Coumadin Dosing calculator perfectly, so that is very good. I have been secure with this knowledge and following along with no problem. My last three INR checks have been a 4.1, at which time they dropped my dose. Two weeks later I was at a 2.4, so they raised my dose slightly, and today it is a 1.9. To complicate matters I am jumping on a plane to Australia in two days, and will be on the plane for 14 hours. That is playing into my worries a bit, as I will be sitting with little activity for quite some time. I am assuming they are going to be raising my dose, but am wondering for those of you who have done this for a long time if I should be taking a half of a pill this morning (5 mg pills, so 2.5mg dose) in response to this. I haven't been too worried about my INR with it bouncing around between 2.4 and 4, but a number starting with a 1.9 with a long plane trip soon scares me a bit. I was looking for the experiences of others to know if this should sufficiently worry me, or if this is not as big of a deal as I was thinking.

 

[AgilityDog]

How long does it take between when you test/report and when your clinic calls to adjust your dose?? It had better be the same day!

I admit, I HAVE increased my dose by taking part of my Rx earlier in the day (the increase amount) when I've been low. Since it takes 3 days to kick in, I thought it was a good idea at the time.

Oh yeah. Have a glass of wine today, tomorrow, and one on the plane :wink2:

 

[Bina]

Some clinics like to react a bit too fast to INRs that are slightly out of range...that INR of 4.1 wouldn't have caused me
to blink an eye or make any changes unless it was a suddenly high INR or consistent high INR that I would want to
bump down a tiny bit. How often are you testing ?

 

[Jason]

I was testing every month, and it was on a monthly check that I was 4.1 and they changed the dose. At that point they put me to every two weeks, and it has gone to 2.4 and then 1.9. I think my changes downward were more due to changes in diet and exercise, so was kind of expecting them. I am just not sure how concerned to be about a 1.9.

 

[D.C.]

I went with home testing and love it. I now test once a week and it givse me a great feeling because I can keep a close eye on it and make small changes. It seems more stable that way also for me. I still have contact with the doctors office each week for a quick chat.

 

[Bina]

I was testing every month, and it was on a monthly check that I was 4.1 and they changed the dose. At that point they put me to every two weeks, and it has gone to 2.4 and then 1.9. I think my changes downward were more due to changes in diet and exercise, so was kind of expecting them. I am just not sure how concerned to be about a 1.9.

This is why I do my own dosing, because only I know what I have done or eaten during the time between tests,
and I really prefer to not adjust the dosing for every little blip.
So, with your INR of 1.9 that is probably because they dropped your dose too much for the 4.1 and they should
have had you test one week after that instead of only 2 weeks later.
With a 1.9 you can be darn sure that I would be checking it again the next day to make sure that it has not
dropped any lower !!!

 

[Jason]

I checked this morning, and it was at 2.2. Directionally positive!

 

[Gail in Ca]

My carbomedic 25mm valve was placed inside a hemashield graft, and my surgeon said my INR could go down to 1.8 and not to worry about it. He actually wants me to keep it at 2.0. However, I try to keep it closer to 2.5. When mine has been at 1.8, it did go down to 1.6 when I did nothing about dosage change. So now, my nurse usually bumps my dosage if it goes down to 1.8. She usually goes up about 5% or a little less.

 

[sarahsunshine]

We have a protocol with our clinic which is, from scratch after surgery:

- Start with a high dose for 2 days. Take an INR and tell clinic
- clinic will call back with adjusted dose (usually to your regular dose)
- Take INR 5 days later. Tell clinic.
- If all is well, don’t expect a call back, but take another INR a week later.
- If all is well, take another a week later.
- If INR is stable (+/- .4, not consistently increasing/decreasing, and staying within range), switch to 2 week testing.
- If 2 week testing is stable for 3 time, do 3 week testing.
- If 3 week testing is stable for 3 times, go to 4 week testing.
- If there is a change in INR that is significant (or a change in lifestyle), alert the clinic and start again at 1 week testing.
- If there is a weird incident (increased bruising, nose bleeds, etc… Take an INR. If it is normal, keep your testing schedule. If out of range, call clinic and start again at 1 wk…

We find that this works great for us. We went almost whole year testing monthly once… Wouoldn’t be surprised if we have to up the dose a little more now, though… Skyler has been more active since his surgery.

 

[Protimenow]

I've increased the interval between testing, from weekly to every 10 days or so. This interval bit me in the butt a few months ago - my INR dropped to 1.2 and I didn't catch it until it was low for probably a few days.

Delaying testing from two or three (or four) weeks still strikes me as a bit foolhardy -- the days of the blood draw and inconvenience of going to a lab for that kind of a test are, fortunately, a thing of the past for most of us. In the current situation - where many of us have our own meters and testing is fast and relatively inexpensive - the motivation to spare us the hassle of getting a blood draw really doesn't exist. I'd rather have TOO frequent testing than worry about being out of range for a week, or two, or more. (And, as you said about 'weird incidents', these probably wouldn't arise if testing is more frequent).

I really don't think there's much reason to put testing off to two or more weeks -- if you can confirm that you're in range more frequently - this is good. If you find that you've slipped out of range (sooner, rather than later), then you can take action to resolve a potentially risky situation.

I suggest that your clinic - or any clinic - should evaluate their protocols based on the relatively inexpensive testing that meters afford versus the potentially dangerous events that could occur BETWEEN infrequent tests.

 

[chaconne]

Delaying testing from two or three (or four) weeks still strikes me as a bit foolhardy -- the days of the blood draw and inconvenience of going to a lab for that kind of a test are, fortunately, a thing of the past for most of us. In the current situation - where many of us have our own meters and testing is fast and relatively inexpensive - the motivation to spare us the hassle of getting a blood draw really doesn't exist. I'd rather have TOO frequent testing than worry about being out of range for a week, or two, or more. (And, as you said about 'weird incidents', these probably wouldn't arise if testing is more frequent).

Hey protimenow! It's been a while since I've seen you post. I'm glad your still around.

I recently had a discussion with a doctor at my Kaiser Permanente Coumadin management clinic. She seemed to want to discourage me from home testing and said that the interval for testing could be as long as 2 months if I'm stable enough. I told her about the possibility of not catching a low INR in-between and she didn't seem concerned about that. She seemed more concerned that frequent testing on a home monitor could lead to fluctuations in INR, or inaccurate readings. So it seems that my clinic, or at least this doctor, is somewhat behind the times and resistant to home testing. I may need to buy my own monitor and just test in parallel without them knowing.

 

[Protimenow]

Chaconne - I don't visit here quite as often as before, but I'm still very concerned with anticoagulation issues. Your doctor's idea that 'more frequent testing on a home monitor could lead to fluctuations in INR' is just plain ridiculous. There's no cause and effect relationship between home testing and INR fluctuations. As others have said, as long as you're in range, there's little reason to do ANYTHING different.

Delaying testing for extended periods is also foolish (I have to admit that in the past, I've gone for unsafe periods, safe (I thought) in the knowledge that I used to be in range and my dosage didn't change). Regardless of how 'stable' your INR is at a particular point - this doesn't indicate what it was BETWEEN tests -- especially if you extend tests out to ridiculous periods (like, say, every two months).

Also -- recent thinking on the risks of a low (1.4 - 2.0, perhaps) INR doesn't make this seem as dire and life threatening as many of us believe. If you're more than three months post-op, the need for bridging is probably minimal. According to the Duke Clinic, just increasing the dose slightly, until you're back in range is enough -- you may not need bridging. (I've posted a link to the protocol in previous posts).

If I was planning to be in an airplane for a long period -- even with a 1.9 -- I don't think I'd worry about a DVT. I'd bring my meter, and continue to test weekly (as long as I have strips, of course)