[HSF] Unusual response to warfarin

[Tea Acuff]

I think that there are probably patients who are quite "brittle" to borrow a word (sorry, Ben). 
The other thing to consider is the usefulness of home testing and patience. Even a mg or two a day when the patient is taking 10mg can make a difference.  There is a lag of around 48 hours or so before what ever you did is noticed. (I learned this  treating my daughter at home despite two decades of "managing coumadin" in my practice...all three points) What you describe is the same thing with the hypersenitive and heavy handed yet diligent nurse (or anesthesiologist, anyone but us) pushing the BP from 60 to 200 and back to 60 with drips in the ICU. Bet you have seen that, too.
The last thing to remember (for which i would like confirmation from our experts) is that our targets (much like our "best practices") are misleading as are my analogical thoughts. As in the ACT on CPB higher is not necessarily "more" anticoagulated or more to the point, less thrombotic, right Ben?, but decreases the frequency of drop to below anticoagulated. I was told by another expert that an INR over 2 is all that is needed, but a level of 2-2.5 means that the patient spends frequent time below 2. (See above.)
tea


----- Original Message ----
From: john pj <john_pj15 at yahoo.com>
To: OpenHeart-L at lists.hsforum.com
Sent: Tuesday, July 10, 2007 4:07:42 PM
Subject: [HSF] Unusual response to warfarin


We have difficulty in managing  warfarin dosing for a patient. Twice she was admitted for embolic episodes and twice with bleeding episodes. We suspected inadequate compliance and hospitalised  for long periods  and realised it not a problem with compliance.
  It takes long time for INR to come up and then it shoots up.INR remains high for long times even with out warfarin. She underwent multiple admissions to manage over and under anti coagulation.
   
  We did not try to change over to acitrom or phenindione as they are not available through public health system.
   
Any suggestions?

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