Difficulties with post sugery meds

       Help! My close friend (50 yrs. old) had valve replacement surgery. It's been almost a year now & her Doctors are having great difficulties in finding the right dosage of coumadin for her. In the meantime she is feeling very sick & tired alot of the time. She's experiencing bleeding from the ears, nose, gums. When dosage is adjusted it's fine for only a short time before difficulties arise again. My questions are, How much longer before the right amount of Coumadin is discovered, & Is it normal to have so many problems & discomfort in the meantime? She's feeling very badly & I was also wondering if there is any alternatives to Coumadin. Can you help her? Sincerely, Titi

[CCF Cardio MD - MTR]

_
Dear Titi, thank you for your question.  Coumadin can be a difficult medication to regulate because each patient processes the medication differently and can have a variable response to the same dose.  Coumadin is metabolized by the liver so any liver dysfunction can slow down metabolism of coumadin to make a commonly-used dose thin the blood more than usual.  Also, coumadin works by antagonizing clotting factors that depend on Vitamin K to work.  When someone taking coumadin has a lot of vitamin K in their diet (by eating leafy, green vegetables), they may require more coumadin than normal.  Finally, many medications interact with coumadin to interfere with its metabolism so possibly, one of her other medications is playing a role.  Despite these problems, there are no long term alternatives to coumadin.  Subcutaneous heparin injections can be given to thin the blood but require injections twice daily and are expensive; thus, heparin is not a long-term alternative to coumadin.  There are no other comparable oral anti-coagulants.  It's hard for me to estimate how much longer it will take to adequately adjust the coumadin since I don't know the details of her previous coumadin dosing.  Finally, the symptoms of weakness and fatigue are non-specific may be a side-effect from a medication or many other medical conditions.  These symptoms, however, are not common after valve replacement surgery unless something else is going on.  Therefore, I suggest that you speak to her physicians about these issues for more individualized information.  I hope you find these comments useful.
Information provided in the heart forum is for general purposes only.  Specific diagnoses and therapies can only be provided by your physician.