INR

I have a mechanical mitral valve for 4 years.Taking Coumadin 6 mg but 3 days ago the result from the Lab was 1. and I'm scare because sometimes I have to go  to the Hospital for that. The Doctor sent me 7 mg daily staring today and  go to the Lab next Friday again.What should  I do?

[skydnsr]

I would not be comfortable with having a mechanical mitral valve and an INR of 1, because an INR of 1 is the same as not being anticoagulated at all.  Which brings up the question, was the result even correct?  If you have been in range for a long time on a stable dose of coumadin, then what the heck happened to drop you down to the same INR as someone who is not even on coumadin at all?  I would want to know either how my INR got so low, or if there is no known reason, was it a false result?  Lab errors do happen.  

There is a type of medication called a bridging agent that can be used to keep you protected while your INR is subtherapeutic.  The most common one is Lovenox, but some people can't take Lovenox.  I use one called Arixtra, when I need it.  Both Lovenox and Arixtra are shots that you give yourself at home.  Arixtra is a once-a-day injection; I'm not sure if Lovenox is given once a day or twice a day.  A doctor or nurse can show you how to give yourself the shots.  The injection will make a blue spot under your skin that looks like a bruise, but it is not painful.  The "bruise" is from anticoagulated blood leaking under the skin, and since it is not from trauma, it does not hurt.  The advantage of using a bridging agent, in comparison to using coumadin, is that the bridging agent starts working pretty much immediately -- unlike coumadin, which takes about 3 days of daily dosing, at least, before your INR will be within range.

Assuming you really do have an INR of 1, and it is not a lab error, I would want a prescription for a bridging agent to use during times like this.  The bridging agent keeps you anticoagulated, but it does not alter your INR.  So whenever your INR gets back in range, that's when you can stop the shots.  

Maybe you will want to have a serious talk with the doctor that is managing your coumadin.  First of all, for an INR of 1, I think someone should have called you immediately.  I assume you tested on Friday and they called you today, Monday.  You should not have been left with an INR of 1 for three days without even a call.  Had they called you promptly, you could have increased your dosage on Friday evening and perhaps been back in range by now.  If you had had a stroke over the weekend, which thank God you did not, they would have failed to do anything to prevent it.

I also think someone should have talked pretty in-depth with you about what could have happened to cause your INR to drop to the level of no anticoagulation.  I hope they did that.  Perhaps they did; you don't state otherwise.  And I also think, if there is no known explanation, that an immediate recheck of the INR would not be a bad idea, just to to rule out a lab error.

[skydnsr]

Medicare and some other insurance plans pay for home INR testing, using a little device that is smaller than a paperback book.  The company that sells the device trains you in how to use it.  Some doctors have the exact same type of device in their offices, and a nurse does the testing and can tell you the result immediately.  Either way, there is no waiting even one day, much less three days, for someone to call you back with your INR result.  If you want to do home testing, I think you have grounds, and if you don't feel comfortable doing the testing yourself, you could check around and see if any PCPs or cardiologists in your area do  the in-office testing.  I used to have lab draws, and sometimes I would not even get a call.  It was very aggravating.  Then I switched to a doctor that has the INR tester in his office, and now I home-test.  I like the little machine, either at the doctor's office or at home.

[REGLA760]

Thank for answer my question. I was on Lovenox for 6 months last year when I was bad with  the INR. In 4 years NOBODY is been taking to me about the consecuences of the low inr and I'm the one who have to call the doctor  for my result when i go to the lab.

[skydnsr]

I'm assuming you are doing your part of the INR management, which is to take your medication consistently, take it as ordered, tell your doctor about any new medications, and show up for your test on time.  The rest of it  -- determining what dosage you should be on and telling you when to test, is up to the doctor.  If I were you, and if I were faithfully doing what I was supposed to do, then I would not be satisfied with having to give myself Lovenox shots for six months, just because the professional who was doing my coumadin management could not keep my INR in range.  

Most people, if they are compliant and if they have a good coumadin manager, can test in range at least about 65% to 70% of the time, and when they are out of range, they usually aren't far from it.  Once you do get out of range, it shouldn't take but a few days, at most, to get you back in.   Unless you are either noncompliant or you have some kind of really unusual medical condition that interferes or interacts with anticoagulation therapy, I don't understand why you have had so many problems.  

There are people out there who take their coumadin haphazardly, and not only is that dangerous in itself, it gets the medical personnel very discouraged about trying to work with you.  Something is not right about your situation.  I don't know what the deal is, but an INR of 1 is not okay.  Not being called about your INR is not okay.  Being called three days later when you have an INR of 1 is not okay.  That's about all I know to tell you.

[Sugie1938]

Hi,  Can you tell me what a normal INR reading should be? My 95 year old Mother has to have her blood tested at the doctors every week too 2 weeks, and her medication changed. This is a hardship on family trying to get her there, and change it so often, as she still lives alone, but unable to take care of medications. Thanks

[REGLA760]

My doctor said that the range of the INR is betwen 2-3

[Yvette BG]

Hi--My Dad is 84 years old and is on Coumadin. Very long story short, he has not been taking his Coumadin medication regularly (along with his diabetes medication, high blood pressure pills, etc. which also can affect his INR readings). When he does go in for INR tests, his INR level is all over the place (sometimes pretty high, could well be  doubling up on pills some days) because of the inconsistency in taking his pills, the great variability in his diet and also in his alcohol intake. His situation is what skydnsr is talking about--it's very hard for the medical personnel to work with him to keep his INR within the desirable 2.0-3.0 range.

His cardiologist recently told us it might be best for him to consider going off the Coumadin altogether and going on Plavix and aspirin instead. He said it's not as good as the Coumadin in managing his chronic atrial fibrillation (he also had an aortic valve replaced in July 2008), but probably safer than his taking the Coumadin willy-nilly and not being monitored but every 3 months (when he comes back from out of the country). I guess you could ask your Mom's doctor what he/she thinks about that as an option. The Plavix, though it's not without its possible side effects as well, apparently doesn't requiring the frequent monitoring that Coumadin does.

There is a new medication coming out that will replace Coumadin and not require the monitoring, I understand, but the doctors say they expect it to be very expensive for a while. That may prove to be a Godsend a few years down the road if they can get the price down and they don't find unexpected side effects or problems they didn't know about.  

[Sugie1938]

Thanks for the good information. Mom still lives alone at 95, does pretty good, but having trouble getting around, uses a cane, and getting a little forgetful. We put all her medicines and OTC in the large pill boxes for 2 weeks, and she has done good remembering. The nurse said lack of exercise and green vegetables can affect the INR. She does eat some green vegetables and salads, soups, but not in excess. Her skin is very thin and the weekly and bi weekly blood tests are hard on her. We discussed this with her doctor, and she tried extending the time between but because it flucated so much, has gone back to more often. She didn't seem to think other options was good for her based on her medicines, etc. We have a therapist come in 2 times a week to exercise her, and friends and neighbors, and family get her out some. Thanks and any other ideas are welcome.

[REGLA760]

It's the INR is high you can't not double the coumadin because it's bad.You should talk to the doctor about that.In my condition  I can't change to another medication except Lovenox  or sometimes Heparin when I am at the Hospital. I prepare all my medication in a pill box for a month and only have to take care about the amount of Coumadin. My INR still on 1 I'm going to see the doctor now.Wish me luck.