Adjusting Coumadin

[David Eugene]

My husband has only been on Coumadin since Sept 18th (after having a slight stroke caused from Afibs) and they are having a hard time adjusting his level. On the 28th, his INR was 4.77 while taking 5 mg. His DR told him to skip 2 days, then take 4mg for 2 days and re-test. His INR dropped to 1.77 (Oct 2nd). My husband took 5 mg again for 4 days and his INR is back up to 4.07 today (Oct 6). His DR again recommends skipping 2 days then taking 4mg and testing the next day. Do you agree with this procedure or is there an easier way to get the correct level range of 2 to 3?

[Angela]

I am not a doctor or nurse, but have been on coumadin for 3 1/2 years now.
From my own experience I have to say that your doctor may be a little inexperienced in coumadin management.
My doctor would have only have me skip one day, and then take the 4 mg for 3 days and then re-test.
You might want to also ask your doctor for a referral to a coumadin clinic, if there is one in your area. They specialize in coumadin monitoring and are typically much more experienced.

Wishing you all the best,

Angela

[aroostook county]

The 4mg is working great for him so far. His INR is now 2.44. He has blood tests every Monday and Friday, except this week it will be on Thursday. I think he will be using the 3mg to keep his INR in the 2 to 3 range.

[Laurie]

David, If his doctor keeps making adjusting to the coumadin this way he will never regulate him. He needs to actually write it out like a math problem. If he holds him for 2 days in a row - that will drop him quite a bit - it is going to lower the inr temporarily -- he needs to adjust the dose "daily" and quit holding for 2 days in a row which will lower it but will show nothing if he keeps doing that. Let me know what his next inr is -- keep a log like you are of what mg he took everyday - what day he had his inr - AND i need to know if he took his coumadin before his test or after , in the evening. My guess is he will need to be on approx 25mg - 27mg a week -- just an estimate, I cant tell unless I knew more.

[David Eugene]

Here is the detailed listing from the first day:

DATE
16-Sep 5 1
17 5 2
18 1.67 5 2
19 5 2
20 5 1
21 5
22 5
23 5
24 5
25 3.71 5
26 5
27 5
28 4.75 0
29 0
30 4
1-Oct 4
2 1.77 5
3 5
4 5
5 5
6 4.07 0
7 0
8 3
9 1.47 3
10 3
11 3
12 1.49 4
13 4
14 4
15 4
16 2.05 4
17 4
18 4
19 2.44 4
20 4
21 4
22 2.74 4

The second column is the INR test result, the third column is the coumadin mg, and the fourth column is the dosages of lovenox to start out. Those shots were 80mg each.

It looks to us that the 3mg will be the stabilizer. We are thinking about taking a 4mg tonight (23rd) then drop to 3mg until the next test on Monday, to see where it is at. He started a new doctor yesterday that told him to continue with 4mg and take a test next Friday. We feel that will raise it too high, and too far in between tests. We are going to continue with the twice a week test for now anyway. What is your opinion? His original doctor wants to keep it between 2 to 3, for Afibs. I wish we could keep the original doctor but he is a hospital doctor and had to transfer him to primary care doctor.

We appreciate your help as we question the new doctor!

[David Eugene]

Sorry, when I posted the chart it came out crammed in with columns. If you can't make sense of it, I will try to post it again.

[David Eugene]

DATE
16-Sep..........5....1
17..........5....2
18...1.67.......5....2
19..........5....2
20..........5....1
21..........5
23..........5
24..........5
25...3.71.......5
26..........5
27..........5
28...4.75.......0
29..........0
30..........4
1-Oct..........4
2....1.77.......5
3..........5
4..........5
5..........5
6....4.07.......0
7..........0
8..........3
9....1.47.......3
10..........3
11..........3
12...1.49.......4
13..........4
14..........4
15..........4
16...2.05.......4
17..........4
18..........4
19...2.44.......4
20..........4
21..........4
22...2.74.......4

Maybe this will work.

[David Eugene]

I forgot to note that the INR tests were taken first thing in the morning so the daily dosage was taken that evening, after the test.

[Laurie]

David, thanks. let me write it all down and take a look and I will try to get back to you tomorrow. You are right on with still checking it 2 times weekly or at least early next week - Mon or Tues and see where hes at -- Friday is way to long to wait.

[Laurie]

David, Actually - figuring it out -- he has been in range the last 3 times -- the doses he was given was 26mg - 28mg - and 28mg -- he should be good on a 4mg daily dose - possibly 4mg daily with the exception of 1 day either 2mg or 3mg. Looks like he is doing good :) Let me know what his next inr is. You could try the dose your talking about - and it should still be okay. Hope this helps - thanks for providing the info - that really helps :)

[David Eugene]

Oct 22...274...4
23..........4
24..........4
25..........4
26.....3.15

Hi Laura, He took 4Mg a day for the past 4 days raising his INR to 3.15 this morning. I think he should take 3mg per day (starting tonight) to keep it from getting higher. Thanks for your help.

[David Eugene]

His doctor just called him and said to skip tonight (Monday) then alternated between a 3mg and 4 mg until he goes again on thursday.

[Laurie]

David,

I am thinking that may be to much holding him today - I think the 26mg a week may work but we will wait and see :)

[David Eugene]

His INR was 1.59 today. In the previous 3 days he had: 0mg, 4mg and 3mg.

[Laurie]

David, so dropping him by 5mg took him down almost 1.5 -- that is odd he dropped that low. I would guess that he may need the 4mg every day except like a monday and friday 3mg. I would like to see how that dose works for him and then check him maybe Wed. He doesnt appear that he is going to jump to high so I would say let him go a week or almost a week on the dose and then check it -- otherwise they will keep changing his dose and he will never be regulated. At 3.1 I think they should have lowered his dose by 2mg for 1 day only and checked to see what happened in a few days.

[David Eugene]

His INR after 7 days is now 2.48 but his b/p was high...186/100, so his doctor told him to stop his 50mg a day of Atenonol and start taking 60mg twice a day of Diltiazem. Is this a safe drug to take with coumadin? Also she recommends continuing with the 4mg a day of coumadin. Will Diltiazem raise his INR?

[Laurie]

David, I dont believe it will. I dont recall ever having to adjust someones coumadin based on Cardizem which I believe is the brand name. Is he checking his BP at home everyday? If not he needs to, when he gets up first thing in the morning then again about 2 hrs after he takes his meds. Make sure he keeps a record of his readings and notify his doctor if they are still high or if they drop to low.

[David Eugene]

Well, he took 24 mg of coumadin for 7 days (3 days at 4mg & 4 days at 3mg) and his INR today was 2.05. Is it common for the INR to drop like this on 24 mg? He did have a few salads (iceburg lettuce & green peppers for Vit K) during the week. His doctor told him to take 4mg for the entire week last week but we were afraid it would be too high again so we went with the 4 days of 3mg. We figured his INR would end up around 2.85. This week we WILL stick to 7 days of 4mg (28mg). At least he is still within range. Maybe his new med does lower his INR a little.

His new med is keeping his b/p lower, most of the time, but his heart rate is higher. It used to be from 40 to 60 but is now from 80 to 60. But overall, he is feeling good.

[Laurie]

David, sounds good. Dont worry about the total mg he is taking as long as he is in range. The salads could drop him a little especially if he doesnt normally eat them as often. His heart rate is still okay.

[David Eugene]

Do you know a safe pain pill to take with coumadin? He has arthritis and nerve pain.