Hi Dee,

It think it depends on how low it drops. I was given lovenox when my INR dropped to 1.2. This was about 4 weeks after I'd started warfarin. But I've been as low as 1.5-1.9 and was not given lovenox. They just upped my warfarin and had me re test in 5 days. One time they had me re test in 3 days but that made no sense to me in hindsight since it can take several days to see the impact of the dosage change. So, what she's telling you doesn't seem that out of line although others here may have different experiences.

In the future, I'd not take "if you don't hear from me" as an answer. She should call you back regardless of what the answer is. You never know- sometimes they forget to call you back or aren't able to talk to the doc right away and so the issue just sits.

Small dosages changes aren't unusual. Seriously, one mg can change everything, so that's why they make small adjustments vs big ones when it's a matter of trying to dial into what is going to work for you.

I don't know what she's getting at with asking you if the bruises are going away. Make sure to ask her when you see her.

It's not unusual to have your INR drop or fluctuate for a while. For some people, they just have to hit that sweet spot with the dosage and it can take a while. So, just know that's kind of a normal part of the whole warfarin / INR management.

To me the bruising sounds like a sign that the warfarin is working at least to a certain extent. I've been in range a while and I've had a few bruises that I'm not sure exactly how I got them or I only vaguely remember hitting that spot. They seem to take a little longer to go away than usual, but as long as they're not really severe, or continue to worsen over time it seems you should be okay in that regard.

My INR is really low today too ... tested at 1.3 this afternoon. I think I've been taking the wrong pills though, since the 1mg and 5mg sit next to each other on my kitchen counter and I've been spacy this week. My doc didn't suggest Lovenox, but I will mention it to her if I'm still low on Monday.

I'm not sure why the nurse is worried about the bruises either. I'm very fair-skinned and bruises take forever to go away on me, both before, during, and after I'm on warfarin. I get them pretty easily now (and I also don't remember hitting that spot most of time), but I haven't noticed a change in how fast they go away.

With the bruises from my Lovenox injections, some of the injections didn't bruise, some bruises lasted only a few days, but I had one that lasted about six weeks (and was huge and scary looking!). Oddly, the long-lasting one was the second Lovenox shot I got in the hospital, 12 hours after I was diagnosed. The huge bruise didn't develop until about a week after the shot. Don't know what that signifies in terms of clotting ... not sure that it signifies anything at all.

I'm with rmb, I'd definitely call the nurse back. They're busy and they forget things. Be your own advocate and call again ...

Hi Dee, it took me a month for my INR levels to come into the therapuetic range. At first I was covered by Clexane shots ( this could be what we call Lovenox in Australia). Once I had 2 consecutive warfarin readings in the right range, these injections finished. However, right afterwards my INR levels fell to 1.8 for about a week. None of the doctors seemed worried about this, but I got a new DVT. It may also have been due to the HRT I was taking then too. I should add that this occured within the first 4 weeks and the time period here might be relevant.My INR levels were checked every 3 days for the first month. The fluctuations are too great to check more frequently than 3 days, but I see no reason to leave it longer if INR levels are not in a therapuetic range. Once my INR levels became more stable, it was 1 then 2 then 3 weeks between tests and my next one is in a month. When my INR levels were not sufficiently increasing, I produced my own record that I had been keeping and pointed out that there seemed to be no point staying on that dose as it was too consistently low. My warfarin dose was reviewed as a result of this and I have not fallen below therapuetic levels since. My doctor said it doesn't matter if it falls below therapuetic range for a couple of days. I watch it myself because the pathology clinic also missed my doctor's notes that my target range was set higher as a result of the new DVT and didn't increase the dosage until I pointed it out. Is there less risk of a new DVT after 4 weeks? Maybe that is why the nurse is not worried and also why the injections stop. You may not need injections, but I can't see why your warfarin dose wasn't increased as you have been on it for 4 weeks. I know they build up slowly at the start, but why not increase the dose now? There may be a good reason, so I would encourage you to push a little more to get an answer and some peace of mind.

What is your INR range? depending on what your range is will decide wether you need those shots. Are you sure that it was Heprin and not Lovenox? Heprin is best given through an IV and you are kept in the hospital to check how your PTT is (PTT is how they measure Heprin and I am not sure of the conversion). As far as checking your PT/INR it is normal to check it weekly when you are just starting Warfarin unless your levels are really low which 1.6 I don't consider really low no matter what your range is. If you have more questions send me an email. I have been on Warfarin for over 13 years and have survived 6 blood clots and 1 PE

Once your INR is stable, they test you less and less so that you end up going in every month.

Bicki makes a good point about keeping your own records. My old PCP's office was from the Stone Age and kept horrible records and they never referred back to my last dosage and INR each time I got it checked. So I had to constantly tell them. Plus, having it in front of me really showed me the trends and it was enough for me to say, I need someone else to manage this because it isn't working with this PCP.

My current PCP keeps electronic records and his staff is always on top of stuff. But I still document my INR and my dosages in a calendar.

For all you folks new to this, what I learned through my DVT/PE experience is that you cannot rely on the nurses or doctors to just tell you what to do and just assume that they're going to steer the ship. You kind of have to get in there and poke them with a stick. They aren't used to being questioned by patients and so sometimes, they get pissed off when you do that but that's their problem.

There are some people who don't even know what their INR is. The nurse will just tell them, it was a little high or a little low and then tell them their dosage. That's crap. We have to ask questions, demand information, and become the project manager for our own care. My original PCPs staff HATED me for this reason.

Dee, let us know what you learn and don't be afraid to ask questions about your care.

Hey there - the thing about bruises is if your bruises don't go away or get bigger and darker, that means you're bleeding under your skin. That is independent of INR - in other words, you could have a 1.6 INR and still have bleeding. So even though I get random bruises, they have always gone away and never got darker or bigger. If they did, I'd get in to see my doc pronto. Just a thing to watch for, not to worry about though.

I took lovenox for 3 weeks while my INR was trying to get into range, and once it got between 2 & 3 they went to warfarin only. My INR immediately dropped, but they did not put me on lovenox again, instead just increased my dosage.

I started out with 5 mgs and today, nearly 2 years later, I'm at 10 mgs on 3 days, 7.5 mgs for the other 4. My INR usually falls, but they no longer adjust my dose, they just test me more frequently now. So I could have a 1.9, but they stay the course with my dosage and test me the next week, where it may be 2.5 or as in this week, 3.8. They hold a dose when I get a (rare) high reading, and test again in a week.

What that all means? They feel I'm safe going low for a bit, but not going high, and they test me more frequently than the once a month good, stable boys and girls get to test.

One last thing about your INR - just because it's low does not mean that your blood is "clotting", so don't lose sleep over that!

Hi I am new to this group but have been on Coumadin for 32 years unfortunately! At one point I was having similar problems with my INR. Also was getting sick very easily and tired alot. Kaiser couldnt figure it out so I went to Mayo Clinic since my Uncle was Head of Neurology at that time. Within a coupld of hours we had the answer. I had APS, Anti-Phospholipid Syndrome. Kaiser didnt have the test for that yet. It is an Auto-Immune Disease fairly rare that messes with your blood. You could mention this to your Dr. or get a Hemotologist if you dont already have one! Good Luck.

I'm with rmb, you absolutely have to be your own advocate. I've told my doctor that when they call with my INR results, I want them to leave me the exact number in their message. None of this "you're OK" or "you're a little high/low" for me. I keep track of my INR on my calendar and I always know where I stand.

I'm also very agressive about calling when I don't hear from my doctor with the results. I've called several times a day and I've called after hours and on the weekend. It is very important to me to stay on top of this.

Also, I have a standing order at my blood draw clinic. This is nice, because it means I can go in to have my blood drawn at any time without talking to my doctor first. I will definitely add extra blood draws to my schedule if I start a new medication or have some other problem that might affect my INR. Better safe than sorry.

Give that nurse a call... I wouldn't wait on that.

I'm 3 months in and still not stable i've just gone from a 3.7 to 1.5 in 2 weeks so back to weekly testing. I've never had the injections to compliment the warfarin apart from the first 3 ish weeks. But i'm not overly concerned and i prefer the weekly or fortnightly bloodtests as i only panic and stress out if it's over that time anyway. I'm not even sure if i will get stable in my treatment time of 6 months as it's never been yet, but i don't change my diet from week to week to show the instablity, so who knows why it's never stable??
In fact i feel like it's still dead runny this week like my 3.7 as my period this week is so heavy (heavier than i've ever had) and i bled loads at my bloodtest (like i did when i tested a 3.7) wonder if that means anything?
I have hopeless doc's and nurses, and i just found someone to take my allergic reaction more serious (thank goodness as it was sore and driving me mad!!)

I am on my 7th month (on for the rest of my life) of Coumadin and finally have stabilized. Yay! I am actually a little nervous because I was told today to wait a month to recheck. I never thought the day would come!

Thank you all so much for your replies. I guess I'm still getting used to all of this and this is really great for putting my mind at rest :)
rmb, thanks for the good advice and the reassurance, I feel much better about it all now, I was a bit worried about being out of range but I suppose once I'm on the warfarin everything should be ok, even if my blood is still clotting.
As far as the bruising goes, I have two big ones that haven't gone away at all, but I'm sure they're fine. I have an appointment on Tuesday with my haematologist, so I can ask her about it then.

I didn't get the chance to call the nurse back yesterday, but they do have a system where they send me the results with the INR level, so I can keep track of the levels as I go along which is good :)

Foster my range is between 2 and 3. It wasn't the same as the heparin that I was on in the hospital, I can't remember the exact name of the other one that I was given outside hospital, but it was something like 'low molecular weight heparin'.

I completely agree that you have to be your own advocate, there have been plenty of times where I've had to chase up on things or correct things, you have to be on the ball all the time, you have to keep yourself informed as much as you can and ask a lot of questions, otherwise they won't be too pushed about giving you the information! and there were lots of oversights too when I was in hospital that put me at risk, but that's another story!

Bikejo I've been really tired a lot and I've been sleeping an unbelievable amount too. I'm sorry to hear that but I'm glad that they found out what was wrong with you.

Thanks again to you all for replying and putting my mind at rest, it makes a big difference :)
Dee