It is a hard call, because at some point those of us who are on warfarin long-term start knowing what will work and what won't. I myself went against doctor's orders this last week and adjusted my meds two days before she said that I should.

I don't like the idea of holding at all. The only time I held my meds was when I hit 4.8 and I guess it made sense then because we really did want my numbers to drop quickly. Otherwise, my instinct (like yours) is to do small adjustments and see how it plays out.

Of course, this is only a one day thing and your INR isn't really that high. I don't know if holding for one day will cause major drops and rises, but I guess you'll see. Life with warfarin is such an adventure!

60 mg over 7 days with a 3.4. to a
50mg over 7 days, ya'll probably have an under therapeutic result.

LauraLu, you know you are correct, 7.5mg as oppose to a hold.
Plus, have a sweet tea.
:P

That's my $0.02 as a non pro, heck I'm just a Cannuckian clotter.

Well why not just reduce your dosage rather than holding? That always seems like a knee jerk reaction to me for something like a 3.4 INR. However, I've inadvertently missed a dosage of warfarin and tested a week later and saw very little movement in my INR at all so it made no real difference. I'd want to know how the lab techs know when to hold a dose, like what's their protocol.

After the disaster that occurred when I listened to the 'professionals' instead of going with my gut instincts, I would go with your gut.
At the end of the day, you've made a reasoned and well thought out decision, if you opt to take 7.5 instead of missing today's dose, and it's your body that you're in charge of.
I don't think 3.4 is all that high, to miss out completely what is a fair sized dose - I used to be on 3 or 4 mg to maintain an INR of 3.

BUT - I'm not a doctor, nurse or whatever, just giving my opinion!

The important part of what I wanted to say was, if their recommendation seems wrong and you're experienced with Warfarin, it concerns your clotting, go with your gut instinct because it's you that gets ill if you get too low, as I found out.

Well, you've been on warfarin and watching adjustments and changes for how long?

And the lab tech has been doing it how long?

I'd probably stick with your gut.

(Wheee! Feelin' rebellious today!)

I agree with you doing the 7.5 mg tonight. This has happened with me a few times. I've been on warfarin for almost 2 years and I take 9 mg everyday.

Several months ago my INR was 3.5 and there was a substitute GP on duty that day. She said to decrease to 5 mg. I decided to decrease to 8 mg instead. When I got it checked 2 weeks later I was at 2.1 so I feel like I made the right decision.

It happened again a few months later when I was at 3.6 and my practitioner said to hold the dose. I decreased to 5 mg instead that day and had it checked 3 days later. My INR had gone down to 3.0 and two weeks after that it was 2.7.

Last summer I had accidentally missed a dose and went from 3.1 to 1.6. This is why I made the decisions I did when I had a high INR, I knew what could happen if I held the dose.

I know everyone's different but I believe we do know our bodies and have a lot of experience with how things affect our INR therefore I trust my own judgment in certain situations. Of course, I let my GP know what I did when I went back for my subsequent INR checks.

I am not a doctor, but the one time I had a high INR the doctor told me to completely skip the 7.5 mg dose for that day. She also reduced the dose to 6 mg per day. It has been in theraputic range every since then.

Really appreciate your advice....If I take the 7.5 dose, do I tell the tech next week? Or do I take whatever INR, high or low, and let her think it's her fault (or credit?)

As you can see, I really dislike decisions like this. If I took my own advice, I wouldn't even consider defying dosage orders, even from the lab tech. But like my dear lifelong-warfarin friends have said here, we get to a point where we sometimes do know better than what we're being told. I don't really fear a temporary low INR (gawd, I've had enough of those anyway) but I do feel put out by the possibility of having to test more frequently for a while, after I've had a taste of being steady for a few months.
And putting that in writing makes me see how many conclusions I've already jumped to...

Tech/nurses new to making dosing decisions usually go straight by a protocol sheet. You however know how your body reacts to dosing changes and may need to respectfully disagree with them. If I hold a dose, my INR drops way too much. If someone new is on duty when I get tested and wants me to hold a dose, I just say "How about I do this ____ instead?" They usually say ok or I'll check with the dr and if he wants something different I'll call you. I never get a phone call.

The guidelines for a slightly high INR are below.

Reference: ACCP Guidelines 2008 + Warfarin Dosing TreeCalc
CONDITION

INR more than therapeutic range but less than 5.0 -No significant bleeding

INTERVENTION
-Lower or omit warfarin dose -Monitor daily -Resume at adjusted dose when INR therapeutic -If only minimally above therapeutic range, recheck INR
with same dose

My old hematolgist would scoff at 3.4 like it was barely a blip on his radar. The tech had a look on her face like I was ready for a fresh frozen plasma infusion.
Thanks Jan, that was helpful too!

It is funny how they react sometimes. Since my range is 2.5-3.5, I don't even adjust my dose unless it is over 3.8.

My primary and I are a little more cautious now with higher INRs, since I had unexplained bleeding into my foot in January while I was at 3.1. We like to keep it around 2.6.

I have to agree that sometimes you just have to pipe up and say "What about ______?" with these dosages. My doc and I usually agree on what to do and we both feel good about it. This last weekend, when I willfully upped my dose two days before she thought I should, I didn't talk directly to her, but rather through her new nurse that I don't like.

I would've talked it out with my doc, but didn't think it was worth the debate with her nurse, who has already proved useful at telling me what I already know ("2.0 *is* in your therapeutic range.") but not useful at looking at the bigger picture (INR has been dropping steadily for a month and I'll probably be sub-therapeutic by next test.) I'll explain what I did to my doc when I talk to her next, but otherwise I'm not going to worry about it.

You nailed it Toss - they miss they big picture. Well, I ended up skipping my dose with the promise to myself that, if my INR does tank because of this decision, I'll be more vocal about it to whoever is calling the shots next time.
Thanks again, everyone. It really is helpful to get your perspectives on this!

You've got us all curious now ... let us know what your next INR is, yes?

You bet. Next week Tuesday....gee, I can hardly wait for my next INR!