INR range chart before death and blood clots

I had a total hysterectomy on January 25, 2010. I developed a DVT in the right shoulder (same arm as IV during surgery). The DVT was diagnosed about nine days following the surgery. I was admitted to a different hospital and spent 6 days there. My issue and question has to do with how often should my primary care doctor check my INR level. He has been having me go to the lab once per week. Last week my INR was 2.9 and I have been taken 5mg of warfarin. This week my INR was 6.6. I am concerned about bleeding to death. Please advise.

[Yvette BG]

My Dad's on Coumadin for chronic atrial fibrillation as well as post aortic valve replacement. His doctors want him to keep his INR between 2.0 and 3.0, preferably 2.0-2.5 which is kind of a narrow range, especially for someone that has trouble maintaining consistency day to day. (Like some days he drinks a lot of alcohol, some days he doesn't; some days he remembers to take his diabetes pill, other days he forgets. These things all can make the INR fluctuate.) They want him to be monitored/INR level checked every 1 to 4 weeks, depending on how much fluctuation he's having and other factors (like whether he just started or discontinued certain other medications.) The highest his INR went, to my knowledge, was 4 something while he was hospitalized once.

6.6 is way too high; what did your doctor say? I know sometimes they give medication to try to bring INR down when it's too high. Did they tell you not to take your Coumadin for a day or two? (When my Dad's INR is over 3.0, the nurse tells him not to take any Coumadin that night.)  

I know it's probably a hassle to go and be checked all the time (my Dad complains), but
since your INR seems to be fluctuating a lot right now (assuming the lab is correct), I  sure would go in as often as they recommend for testing and not miss any checks right now. Also, make sure to tell whomever is checking your INR and adjusting your Coumadin when you go on or off medications, had dosage changes, and also if you've changed your vitamins, started using any herbs, started taking other over-the-counter items, etc. Sometimes this information slips through the cracks and it is very important. Also, if change your alcohol intake,, make sure to let them know--even if they've said you're not supposed to drink, if you are having alcohol they need to know that you are and how much, etc.

Please let us know how things go. Good luck!

[skydnsr]

Yes, if your INR jumps up that much and that unexpectedly within one week, then I'm afraid you need to keep on testing weekly until things stabilize.  You've only been on the coumadin what, two or three weeks?  That's a really short time, and it's not unusual to see a lot of fluctuations in the first few months on the drug.  It takes a while to find the right baseline dose that is the "sweet spot" for you, and it also takes a while for you, as the patient, to learn all the things that can affect INR.  It can even take a while to get in the habit of taking the pills consistently.  I use a 7-day pillbox, so I can actually see whether I have taken my pill for the day or not.  Sometimes I still make a mistake, even with the pillbox, but the pillbox does help.

I have been on coumadin for five and a half years, and I have read everything I can about coumadin management.  From my experience and what I have read, I agree with the comments of Yvette BG, above.  The only thing I might add is that I would question any doctor who wanted to "give medication to try to bring the INR down" for an INR of 6.6.  The medication that can be given is vitamin K, and the problem with giving it is that you then have a big dose of something in your system that is going to make it harder for you to get back to a stable dosing regimen.  If you are bleeding, well, they probably have to give you vitamin K, but as long as you are not bleeding, you don't need it unless your INR is way, way higher than 6.6.  I have had INR's between 5 and 8 about five or six times, and I've never had any bleeding and have never had to take vitamin K.

With an INR of 6.6, as long as you are not bleeding externally, and you are not showing any signs of bleeding internally, you will want to manage the situation by stopping coumadin temporarily.  Holding one to two doses would be appropriate.  Most doctors that know what they are doing will tell you to hold two doses.  Some might say one and a half.  Some might say one, and that would be okay if you test again within the next three days or so.  Holding 1.5 to two doses, you can test again in a week.  I personally would hold one and a half doses and test again in a week.  In other words, I would not take any coumadin at the time of my next scheduled dose, and I would take a half dose at the dosing time after that.

For more information about warfarin management, see www.warfarinfo.com.  I will also try to find the link to an American Family Physician journal article about warfarin management that tells you what dosage adjustments to make, in order to achieve a given INR.  It also tells when vitamin K administration is appropriate.

[skydnsr]

PS, Even at an INR of 6.6, spontaneous bleeding is highly unusual.  If there is any bleeding at all, which there probably won't be, it will tend to be something minor like a nosebleed or some slight bleeding from your gums.  Nothing that will kill you.  Don't panic, you will be alright.  The INR falls really fast if you miss even one or two doses, so it doesn't take long to get the INR down.  The biggest danger would be if you were to get a head injury while your INR was high, and then you would be at higher than normal risk of a brain bleed.  But that is not an everyday occurrence, and I think we can pretty much count on it's not happening today.  Just don't take up hang-gliding, martial arts, or moto-cross today; wait at least two or three days.  You will get used to all of this, I promise, and you won't worry after a while.  It is just all new.

[skydnsr]

BTW, may I ask what did the doctor advise when you turned up with the 6.6?  Inquiring minds want to know.