Friday, December 21, 2007

Warfarin rears its ugly head

I swear I have seen more intracerebral hemorrhages from Coumadin in the last year than in the any of the literature stating it's incidence. Last night I admitted an elderly gentleman who was in his usual state of health until he slipped on the ice and bumped his head. He then carried about his business for a day and a half. Then as he went to work his secretary noted him acting unusual.

When he showed up in my Emergency department, he had an INR of 9.4

For all of those who don't know what an INR is, 1.0-1.4 is normal. This is abnormal, big time.

He had traditionally been on a very low dose of coumadin (I.E. poor metabolizer) The problem was not that he just had very thin blood, the problem was the huge bleed he had in his brain!
What can we do about this problem? I have mentioned the future of coumadin therapy several times. I was just speaking to Dr Isadore Rosenfeld yesterday who pointed out to me that a recent study once again shows how beneficial Warfarin is in preventing strokes caused by a condition known as Atrial Fibrillation. The incidence of Atrial fibrillation increases as the population ages. Therefore, I am certain that we will begin to see more poor metabolizers and even more poor outcomes.
The Sherpa Says: On Coumadin? Mind your INR? Starting Coumadin? Get your metabolizer status checked! If you are in NYC or Greenwich come see us. Thank you to GTO for the early Christmas present....


Jim Hill said...

It is me again. Jim Hill. An INR of 9.4 is not the problem of warfarin. It is the problem of warfarin monitoring. If your patient had been testing weekly with a reliable device at home (ie CoaguChek S or XS) then he would have not had such a bleed.

Additionally, do you know what an INR of 9.4 really is? Probably not. Above 4.5 there is no known world standard for determining the accuracy of the INR.

Why was he at such a high INR? My guess is that the patient was coming in once every 3-6 weeks to a lab for testing rather than weekly testing. With todays technology let's be frank about the proper way to monitor warfarin treatment rather than bash it and look to gene testing as a way out of poor monitoring.

Steve Murphy MD said...

Yes, I knwo about the algorithmic scale of Warfarin and the lack of consensus......I did do a residency in Internal Medicine ;(

Patient was not non-compliant....home monitoring is nice....I agree. Does the monitor cost less than the genetic test?