Your thoughts on dad's current dose....

[Jiddo]

Hi All.

Hope you are all doing well. I just wanted to get your thoughts on my dad's dosing.

You may recall that my dad's last INR reading was 2.4. 2 weeks later he had a reading of 2.7. Then, he went to Vegas and came back 2 weeks later and had an INR of 1.9. I'm attributing the decrease to a change in eating habits for the week while he was in Vegas and/or the amount of walking he did. So, I didn't freak out but worked with the pharmacist to adjust his dose by 5% (from 92.5 mg to 97.5 mg) and then he re-tested one week later (so soon because he took the flu shot). His INR was then 2.4. I spoke with the pharmacist and she said she wanted to drop his coumadin back down to 92.5 mg because he had some good readings at that dose and because he was back to his normal routine when he came back from Vegas. I initially wanted to keep it at 97.5 but she talked me out of it. What are your thoughts? Do you think this approach makese sense?

Also, every time I tell my dad to increase his dose, he is very hesitant. I always tell him that we have to adjust his dose to keep his INR in range, so that makes sense to him. However, he just told me he is concerned about increasing his dose because he thinks this will increase his chances of bleeding. Is he right? Or, does the chance of bleeding increase only if he is above his target range?

Thanks for your help, everyone!

Jennie

 

[Bina]

I assume you are talking about spontaneous internal bleeds, those would only occur if he was really high....and I mean really high.
How much warfarin we take does not make us bleed more, only a very high INR will increase the risk of uncontrolled bleeding. An INR reading of 4.0 is not even anything to get excited about.
I would keep him on the 97.5 since his INR is only 2.4 and try to keep testing weekly or every second week.

 

[Blanche]

Your father's serious problem is not the amount of Coumadin he is taking. His continuing problem is the person who is regulating his anticoagulation. She obviously does not understand anticoagulation and she is giving him information that might be harmful to him. This is not going to change until your father changes to someone who knows anticoagulation.

She may be worrying about internal bleeding. I would be worried about a stroke. My husband had several strokes because his INR was too low. The worst stroke he had, the one that put him in hospital for almost 5 weeks, happened with an INR of 1.8. Your father's INR has been very low several times.

Since it's unlikely that your dad will choose someone else to monitor his anticoagulation, the only suggestion that I have is for you to gather articles and papers about Anticoagulation, especially those from the American Heart Association and provide them to the pharmacist. This probably won't change anything, but it certainly is worth a try. There are many articles on this topic right here on this board under "Reference Sources: Must Have References."
http://www.aafp.org/afp/990201ap/635.html
www.warfarinfo.com
Blanche

 

[Ross]

Jennie I'd do as YOU were going to do and that's the 97.5. If he starts to climb out of of range, then you can back off, but don't back off until that happens. If his INR were 8 or above, I might start to worry a little about bleeding, but not so when he's not even in range.

 

[Karlynn]

Please tell your Father that those of us that have been on Coumadin for years know all to well that the medical community is MUCH too concerned with bleeding, when risk of clot and stroke is much more of a reality and bleeding tends to get the attention by about 10-1 over clots. This is why we have the saying 'It's easier to replace blood cells than brain cells'.

He wasn't even in the upper end of his range when the pharmacist wanted him to drop back to his other dose. That's ridiculous. When we have people who come on with warfarin issues one of the first things we do is ask their dosing and INR history. Quite often we see that their managers are messing around with their dose way too much.

At this point in time - you are more knowledgeable than the pharmacist managing your Dad.

 

[geebee]

I would keep him at the 97.5. If his INR gets above 3.0, then you can be slightly concerned and back off the dose a little. It may very well be that the lower dose ends up being what he needs but, to adjust the level before the fact, is just plain mismanagement.

I have been above 6.0 a few times over the years (27 years on coumadin this coming Wednesday) and nothing bad happened. I even hit my head very hard during a fall and my INR was 4.3 - no issues.

It is very great that you are so involved - please stay so and try to convince your father that a bleed is not going to be an issue with his current INR levels.

 

[Jiddo]

Hi everyone.

Thanks for your advice. I spoke to my dad yesterday about increasing his dose for the week but he was hesistant since the pharmacist already endorsed it. So, I explained my concerns and we made an agreement that he would go in and re-test tomorrow, which is one week from when he resumed the previous dose of 92.5. I feel comfortable with this.

On another note, since my dad has had some low readings in the past, does this increase the liklihood of future problems? Or, does the risk go down once he is able to get back to his target range?

Thanks again.
Jennie

 

[Bina]

That's the nice thing about ACT, whatever is in the past stays in the past.
It's nice to keep track on paper of what has happened, but it in no way has any bearing on the future.
We try our best to stay safely in range.

 

[Karlynn]

Testing weekly would probably be a good idea for now - except that means you'll do battle with the pharmacist on a weekly basis.

If he's in range - then he's in range - the dose shouldn't be messed with at that time. This is why I think the pharmacist was showing her lack of knowledge by putting him back on a lower dose for an INR that was in-range. If it's uncertain whether that dose is continuing to send him up or down, then you retest in a week to see. If his range is 2.0 to 3.0, then IMHO the dose shouldn't be messed with unless it's below 2 or above 3.5. (And I'm being conservative by saying 3.5 - I don't mess with my dose unless my INR is a full 1.0 above my high end range and then I just tweak it a bit.)

Your Father is so blessed to have you helping him look after his INR. Keep up the good work!

 

[Karlynn]

Karlynn has more experience than I do.

Rachel - you always give good solid advice. Maybe the fact that we both know that INR management isn't rocket science means that even a chimp could probably learn. So what does that say for some of the poor warfarin managers out there.

 

[Cooker]

Rachel - you always give good solid advice. Maybe the fact that we both know that INR management isn't rocket science means that even a chimp could probably learn. So what does that say for some of the poor warfarin managers out there.

There ya go with the chimp jokes again..........will this never end???

View attachment 5228

 

[Ross]

Testing weekly would probably be a good idea for now - except that means you'll do battle with the pharmacist on a weekly basis.

If he's in range - then he's in range - the dose shouldn't be messed with at that time. This is why I think the pharmacist was showing her lack of knowledge by putting him back on a lower dose for an INR that was in-range. If it's uncertain whether that dose is continuing to send him up or down, then you retest in a week to see. If his range is 2.0 to 3.0, then IMHO the dose shouldn't be messed with unless it's below 2 or above 3.5. (And I'm being conservative by saying 3.5 - I don't mess with my dose unless my INR is a full 1.0 above my high end range and then I just tweak it a bit.)

Your Father is so blessed to have you helping him look after his INR. Keep up the good work!

Couldn't have said it any better. Good Job.

 

[Karlynn]

There ya go with the chimp jokes again..........will this never end???

View attachment 5228

Ahhhh, Cookie, I'm so very sorry for hurting your little chimp feelings.

 

[Jiddo]

just what we expected....

just what we expected....

Hi guys.

I just got my dad's INR result online and it's 2.0 (in range but on the low end). I left a vm for the pharmacy about an hour ago to call me back so we can talk about the upcoming dose.

So, I'm thinking a 5% increase from 92.5 mg back to 97.5 mg for the next couple of weeks.

Let me know if anyone is not in agreement.

Geez.....why can we predict that his INR would go down but the pharmacist could not? This just doesn't make any sense to me.......

 

[Bina]

I thought you were going to stay on the 97.5 dosage, it seems to be what he needs right now.

 

[Karlynn]

Geez.....why can we predict that his INR would go down but the pharmacist could not? This just doesn't make any sense to me.......

Because the pharmacist is too darned concerned about him bleeding and not as concerned about a stroke because she feels better with him lower than higher. If he is forced to continue with this management provider, you may need to convince him to tell them what they want to hear and then do what you think is right.

It's management like this that makes me wonder why the incident %age of stroke isn't more than it is.

 

[catwoman]

Geez.....why can we predict that his INR would go down but the pharmacist could not? This just doesn't make any sense to me.......

I'm not surprised.

Does the pharmacist only handle anticoagulation testing? What experience/certification/training + continuing education has he/she had in ACT?

You have only your father's case to keep up with, therefore you have more time + energy + interest to better manage his INR. A pharmacist has many more patients/concerns to address, therefore unless he/she is certified in ACT (as Al Lodwick is) and handles ONLY ACT patients, you're not apt to get the best results from him/her. NOTE: I'm generalizing by using apt.

Also, some of the algorithm charts used in ACT are extremely conservative in upping dosages. I've seen the one that our PCP's office uses, and have provided a copy of Al Lodwick's chart -- just so the folks there know where I'm coming from when I change my husband's warfarin dosage.

 

[warrenr]

fear of bleeding

fear of bleeding

Hi All.

Hope you are all doing well. I just wanted to get your thoughts on my dad's dosing.

You may recall that my dad's last INR reading was 2.4. 2 weeks later he had a reading of 2.7. Then, he went to Vegas and came back 2 weeks later and had an INR of 1.9. I'm attributing the decrease to a change in eating habits for the week while he was in Vegas and/or the amount of walking he did. So, I didn't freak out but worked with the pharmacist to adjust his dose by 5% (from 92.5 mg to 97.5 mg) and then he re-tested one week later (so soon because he took the flu shot). His INR was then 2.4. I spoke with the pharmacist and she said she wanted to drop his coumadin back down to 92.5 mg because he had some good readings at that dose and because he was back to his normal routine when he came back from Vegas. I initially wanted to keep it at 97.5 but she talked me out of it. What are your thoughts? Do you think this approach makese sense?

Also, every time I tell my dad to increase his dose, he is very hesitant. I always tell him that we have to adjust his dose to keep his INR in range, so that makes sense to him. However, he just told me he is concerned about increasing his dose because he thinks this will increase his chances of bleeding. Is he right? Or, does the chance of bleeding increase only if he is above his target range?

Thanks for your help, everyone!

Jennie

Jiddo,

It is stated that for every bleeding event coumadin causes, it prevents 20 strokes.
Also, in general a person with an inr of 1.5 vs 2.0 is 3.3 times more likely to have a stroke. I can't remember the specific odds ratio's for 1.5 vs 2.5, 1.5 vs 3.0 etc. but I can dig up the graph if you would like.

This is from the American Academy of Family Physician's (AAFP).
http://www.aafp.org/afp/990201ap/635.html

Warfarin (Coumadin) is the most frequently prescribed oral anticoagulant, the fourth most prescribed cardiovascular agent and the overall eleventh most prescribed drug in the United States,1 with annual sales of approximately $500 million.2 Nonetheless, in 1995 the Agency for Healthcare Policy and Research (AHCPR)3 reported that warfarin is greatly underutilized for stroke prevention. The AHCPR noted that physicians are reluctant to prescribe warfarin, in part because they are not familiar with techniques for administering the drug safely and fear that the drug will cause bleeding. Patients treated with warfarin do require close monitoring to avoid bleeding, but it has been shown that the drug prevents 20 strokes for every bleeding episode that it causes.3

You should show info like this to your dad's act manager.

Keep educating yourself about anticoagulation on your father's behalf. It may save his life some day. Had I educated myself before my father's stroke he would probably be alive today.

 

[Marty]

Warren, I have never seen a better synopsis and review of ACT than this 1999 reference. I refer all new patients and some doctors to it. How are you?
Anything new on the litigation in Ohio? Warm regards, Marty

 

[Jiddo]

Hi All.

Just wanted to let you know that I spoke with the pharmacist yesterday and she agreed to bump up the dose from 92.5 mg to 95 mg for the week and re-test in 7 days. I feel okay with this.

On another note, does anyone else have a hard time sleeping at night thinking of all the things that can happen with coumadin? I understand it's a drug not to be feared but if I am being honest, sometimes I fear it. I was just reading on a past thread that even someone who is in range can still experience a bleeding episode or clot. Gosh, is this true? Don't get me wrong, I know this drug is saving my dad's life but sometimes it's overwhelming just thinking about it. Am I just too paranoid?

Warren, I'm sorry to hear about your dad. It sounds like you are trying to turn something negative into something postive.

Catwoman, my dad goes to an ACT clinic that manages thousands of patients. I'm familiar with a handful of the pharmacists/technicians but don't know their backgrounds in depth.

Thanks again to all of your for your ongoing support/advice.

Jennie