INR of 4.5 What does this mean?
What an INR Level of 4.5 means
What happens when your blood is "dangerously thin"
Having blood that is "dangerously thin" means you are at a greater risk of internal bleeding. You should report any falls or accidents, as well as signs or symptoms of bleeding or unusual bruising to your healthcare provider.
The most serious internal bleeding can happen in your stomach or head.
Serious Internal Bleeding Symptoms
- An unusual or severe headache may signal intracerebral bleeding (bleeding in the head)
- A severe stomach ache may signal gastrointestinal bleeding (bleeding in the stomach)
Excessive bleeding can occur in any area of the body.
Other Internal Bleeding Symptoms
- Prolonged bleeding after minor cuts
- Prolonged menstrual bleeding
- a nosebleed
- vomiting blood
- bleeding from the gums
- Blood in urine
- Bloody or dark stool
Bleeding Inside the Head
Your INR is 4.5 and is greater than or equal to 4.5. If this continues for prolonged periods of time, the chance of bleeding inside the head increases significantly.4
Treatment for an INR of 4.5
Since your international normalized ratio (INR) is outside your therapeutic range, your doctor may opt to adjust your current Warfarin therapy plan.
DO NOT attempt to self-medicate. ALWAYS consult your doctor and follow his/her treatment plan.
These are some scenarios you may experience:
Stopping Lovenox Coverage
If your doctor prescribed Lovenox, then he/she will want to stop the Lovenox to avoid your blood from getting "too thin". He/she will want to recheck your INR in 4 to 7 days.6 This is because your INR of 4.5 is above your target INR range.
Lovenox is a Low Molecular Weight Heparin Blood Thinner. Low Molecular Weight Heparin or LMWH is more convenient and has fewer side effects than standard Heparin and requires fewer shots. Lovenox is injected into the abdomen and is approved for the treatment of a DVT or Pulmonary Embolisms.
Mini Dose of Vitamin K
Your doctor may consider giving you a mini-dose of oral Vitamin K to bring your 4.5 INR down into your target INR range.10
Your Doctor May Do Nothing...
No dosage adjustment may be necessary if your last two INRs were in range and the reason for your high INR can be pinpointed to a factor like acute alcohol ingestion or a decrease in your normal vitamin k intake. The doctor should only follow through with making no changes if he/she doesn't think there's a risk of internal bleeding.10
Decreasing Your Normal Dosage
If there isn't a clear explanation for your INR of 4.5 to be out of your target INR range, then your doctor would decrease your Warfarin maintenance dose by 5%–15%. The doctor will want to recheck your INR in 4 to 7 days.6, 10
If You're Experiencing Life-threatening Bleeding
Your doctor will give you a prothrombin complex concentrate and 10 mg of vitamin K1 by infusion. Your doctor may repeat if needed. This treatment is to stop the bleeding.
A prothrombin complex concentrate is a combination of blood clotting factors prepared from fresh-frozen human blood plasma. It's used to reverse the effects of Warfarin when bleeding occurs (e.g. in the brain or gut) requiring rapid action to accelerate coagulation (speed up clotting).1
How long an INR of 4.5 will last
Warfarin stays in the body for a long time. Every 20 to 60 hours, half the Warfarin in your body will be gone (metabolized).8 A single dose of Warfarin can last two to five days in your body. 7
If your Warfarin dosage was recently changed, the change in dosage may not make a notable difference in your INR for around 72 to 96 hours (three to four days). 9
When you should have another INR test
Since your INR of 4.5 is out of the target range you should test frequently until your INR Level is in its target range. This could be every 4 to 7 days.2
These are some additional reasons you may need to test your INR more frequently:
When You First Begin Warfarin Therapy
When you're starting out with Warfarin, you should be monitored by your doctor 4-5 times a week until there's consistency with your INR test results.
Changes To Your Medications or Condition
When there are changes to medications you're taking or your medical condition You need to test more frequently because drugs and dietary changes can significantly interact with your Warfarin therapy.
When You Use Warfarin and Heparin at the Same time
When you are using Warfarin and Heparin You need to test more frequently and closely monitor your INR Level because the effect of heparin on your INR Level can lead to over-estimation of the therapeutic level of your Warfarin therapy.
Reasons your INR can fluctuate
Your INR of 4.5 is higher than your target INR range, and the following interactions could be reasons for that.
Vitamin K and your INR
If your diet changed and you took less vitamin k than you normally do, then your INR will have gone up.
It is important to have Vitamin K in your diet. The USDA recommends 90 mcg of Vitamin K every day. However, Vitamin K impacts your INR. So you should aim to have the same amount each day.
Not having any vitamin k in your diet is bad advice, because then if you falter in your diet and have some vitamin k, your Warfarin therapy would interact with the sudden increase in vitamin k. Also, vitamin k is an important vitamin.
Supplements That Increase your INR13
|Dong Quai||Coumarin derivative|
|Red Yeast Rice|
Drugs That Increase Your INR11
|Carbamazepine||Carbatrol©, Epitol©, Equetro©, Tegretol©, Tegretol©– XR, Teril©|
|Nafcillin||Nallpen© In Plastic Container|
|Omeprazole||Nexium©, Prilosec©, Prilosec© OTC, Zegerid©, Zegerid© OTC|
|Pioglitazone||Actoplus© Met, Actoplus© Met XR, Actos©, Duetact©, Oseni©|
|Rifampin||Rifadin©, Rifamate©, Rifater©, Rimactane©|
Alcohol And Your INR
Binge drinking alcohol will bring your INR up. Drinking 1-2 drinks will bring your INR down.13
Cranberry Juice and Grapefruit Juice
UC San Diego Anticoagulation Clinic recommends, in general, an interaction between warfarin and cranberry products is NOT expected. What they advise, as with everything, is moderation - have a glass, not a gallon of cranberry juice.
The same goes for grapefruit juice.13
Supplements / Foods
The following can increase the risk of bleeding because of their antiplatelet effect.13
- Fish Oil/Omega 3 Fatty Acids
Drugs That Increase the Risk of Bleeding11
|Drug||Brand Name(s)||Type of Drug|
|celecoxib||Celebrex©||Nonsteroidal Anti-inflammatory Agents|
|diclofenac||Arthrotec©, Cambia©, Cataflam©, Voltaren©-XR, Zipsor©||Nonsteroidal Anti-inflammatory Agents|
|diflunisal||Nonsteroidal Anti-inflammatory Agents|
|fenoprofen||Nalfon©||Nonsteroidal Anti-inflammatory Agents|
|ibuprofen||Advil©, Midol© Liquid Gels, Motrin©, Profen©, Tab-Profen©||Nonsteroidal Anti-inflammatory Agents|
|indomethacin||Indocin©||Nonsteroidal Anti-inflammatory Agents|
|ketoprofen||Nexcede©||Nonsteroidal Anti-inflammatory Agents|
|ketorolac||Sprix©||Nonsteroidal Anti-inflammatory Agents|
|mefenamic acid||Ponstel©, Treximet©, Vimovo©||Nonsteroidal Anti-inflammatory Agents|
|naproxen||Aleve©, Anaprox©, Anaprox© DS, EC-Naprosyn©, Naprelan©, Naprosyn©||Nonsteroidal Anti-inflammatory Agents|
|oxaprozin||Daypro©||Nonsteroidal Anti-inflammatory Agents|
|piroxicam||Feldene©||Nonsteroidal Anti-inflammatory Agents|
|sulindac||Clinoril©||Nonsteroidal Anti-inflammatory Agents|
|dipyridamole||Aggrenox©, Persantine©||Antiplatelet Agents|
|citalopram||Celexa©||Serotonin Reuptake Inhibitors|
|desvenlafaxine||Pristiq©||Serotonin Reuptake Inhibitors|
|duloxetine||Cymbalta©||Serotonin Reuptake Inhibitors|
|escitalopram||Lexapro©||Serotonin Reuptake Inhibitors|
|fluoxetine||Prozac©, Prozac© Weekly, Sarafem©, Symbyax©||Serotonin Reuptake Inhibitors|
|fluvoxamine||Luvox©, Luvox© XR||Serotonin Reuptake Inhibitors|
|milnacipran||Savella©||Serotonin Reuptake Inhibitors|
|paroxetine||Paxil©, Paxil© CR, Pexeva©||Serotonin Reuptake Inhibitors|
|sertraline||Zoloft©||Serotonin Reuptake Inhibitors|
|venlafaxine||Effexor© XR||Serotonin Reuptake Inhibitors|
|vilazodone||Viibryd©||Serotonin Reuptake Inhibitors|
What a target INR range of 2 to 3 means
Your INR target range is between of 2.0 to 3.0, which is preferred for people with the following conditions:1
- Treatment for deep vein thrombosis (DVT) - blood clot in leg
- Treatment for pulmonary embolism (PE) - blood clot in lung
- Prophylaxis of venous thrombosis (high-risk surgery)
- Tissue heart valves
- Acute Heart Attack
- Valvular heart disease
- Atrial fibrillation
When You Are in Your Target INR Range
It is safer when you are in your target INR range, because the risks of an INR lower than your target range could indicate potential clots and an INR higher than your target range could indicate potential bleeding events.
Staying inside your target INR range of 2 to 3
Your INR of 4.5 is out of your target range. Due to Warfarin's unpredictable pharmacokinetics, studies have found that patients only spend about 60% of time within the therapeutic range.5
Since your INR Level is out of its target range your doctor will likely make dosage adjustments. However, make sure your doctor is taking into account the 4 D's! 3
Tell Your Doctor About Your 4 D's
These factors may be the reason your INR being out of its target range:
- Diet - any major changes (fasting, weight watchers), liver or 7 consumption?
- Drugs - any new medicines, discontinued medicines since last INR check?
- Dose - confirm current Warfarin dose, any missed doses?
- Disease - any recent illness, fever, N/V/D, significant pain or stress?
Antibiotics/Antifungals and High INR Levels
Whether you are taking a topical antibiotic or one in pill form, antibiotics can suddenly elevate your INR.11, 12
"A patient could be stable at 2.5, and with an antibiotic, jump to 5. At this level, the risk of gastrointestinal bleeding increases, and a bump on the head could become a bleed in the brain," says Dr. Tejal Gandhi, associate professor of medicine at Harvard Medical School and an expert on outpatient drug safety.
It is important to regularly have an INR test when you are taking an antibiotic/antifungal with Warfarin because the effect of an antibiotic/antifungal on any individual cannot be predicted. Your doctor may reduce your dosage if he/she sees a spike in INR due to the antibiotic.
"It is most important to monitor Warfarin patients as soon as they start a new antibiotic. If we see a small rise in INR with a two to three-day course of prophylactic antibiotics before dental work, we may not worry, because the antibiotic leaves the system quickly. However, if we see an upward rise in INR with a common, broad-spectrum antibiotic such as erythromycin or ciprofloxacin, we must decide whether we need to adjust the dose downward and continue monitoring the patient," says Lynn Oertel, clinical nurse specialist for the anticoagulation management service at Massachusetts General Hospital.
Antiphospholipid Antibodies will throw your INR off!
If you have Antiphospholipid antibodies (lupus anticoagulants) in your body, then you may experience incorrect INR results. There are special INR machines designed to more accurately measure an INR for someone with Antiphospholipid antibodies. It is important to test whether you have Antiphospholipid antibodies so your doctor can take this into account. This is also called Hughes Syndrome.
The APS Foundation of America recommends that if you have APS, then your INRs should be checked from blood drawn from a vein and tested in a laboratory rather than from finger stick machines. It's important that your INR reading is correct, because if you're treated for an incorrect INR, it could have dire consequences.
How Warfarin "thins" the blood
Warfarin, also known by the brand name Coumadin® does not actually "thin" the blood or dissolve clots. Instead, it increases the time your body takes to clot by blocking the clotting factors that let your blood clot. So, after a clot has occurred, the goal of blood thinners is to prevent further extension of the blood clot and prevent future clots. Your body will naturally break down the blood clot while the blood thinner prevents additional clots from forming and prevents current clots from growing or dislodging and getting stuck somewhere else.7 However, saying that is a mouth full, so most often a Warfarin patients' blood is referred to as "thin" or "thick."
In addition, Warfarin does not reverse ischemic tissue damage (damage to your tissue when it is deprived of oxygen from a clot).
Other INR Levels near your INR of 4.5
- INR of 4.1 - what it means
- INR of 4.2 - what it means
- INR of 4.3 - what it means
- INR of 4.4 - what it means
- INR of 4.6 - what it means
- INR of 4.7 - what it means
- INR of 4.8 - what it means
- INR of 4.9 - what it means
General INR Levels
- Kuruvilla, Mariamma, and Cheryle Gurk-Turner. "A Review of Warfarin Dosing and Monitoring." Proceedings (Baylor University. Medical Center). Accessed March 27, 2015. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1305837/.
- "LABORATORY MONITORING OF ORAL ANTICOAGULANT THERAPY." Utmb Health. Accessed March 27, 2015. http://www.utmb.edu/LSG/Pages/ORAL_ANTICOAG_THERAPY.aspx.
- "UC San Diego Health System." UC San Diego Health System. Accessed March 27, 2015. http://health.ucsd.edu/specialties/anticoagulation/providers/warfarin/Pages/dose-adjustments.aspx.
- "Drug Information Center." University of Illinois at Chicago. Accessed March 27, 2015. http://dig.pharm.uic.edu/faq/roleofvk.aspx.
- "To Bridge or Not to Bridge." University of Texas at Austin. October 7, 2011. Accessed March 27, 2015. https://www.utexas.edu/pharmacy/divisions/pharmaco/rounds/10-07-11rounds2.pdf.
- "Protocol Anticoagulation." Rutgers New Jersey Medical School. Accessed March 27, 2015. http://njms.rutgers.edu/departments/medicine/divisions/clinical/guide/protocol.cfm.
- "COUMADIN® TABLETS (Warfarin Sodium Tablets, USP) Crystalline COUMADIN® FOR INJECTION (Warfarin Sodium for Injection, USP)." Federal Drug Administration. Accessed March 27, 2015. http://www.accessdata.fda.gov/drugsatfda_docs/label/2010/009218s108lbl.pdf.
- Horton JD, Bushwick BM. Warfarin therapy: evolving strategies in anticoagulation. Am Fam Physician. 1999;59:635–646.
- Hirsh J, Dalen JE, Anderson DR, Poller L, Bussey H, Ansell J, Deykin D, Brandt JT. Oral anticoagulants: mechanism of action, clinical effectiveness, and optimal therapeutic range. Chest. 1998;114(5 Suppl):445S–469S.
- "Warfarin Maintenance Dosing Nomogram." University of Washington. Accessed March 27, 2015. http://depts.washington.edu/anticoag/home/content/warfarin-maintenance-dosing-nomogram.
- "Interactions with COUMADIN." Coumadin®. Accessed March 27, 2015. http://www.coumadin.com/pdf/Interactions_With_COUMADIN.pdf.
- "Warfarin Users, Beware of Antibiotics." Harvard Health. Accessed March 27, 2015. http://www.health.harvard.edu/heart-health/warfarin-users-beware-of-antibiotics.
- "Food and Supplement Interactions." UC San Diego Health System. Accessed March 27, 2015. http://health.ucsd.edu/specialties/anticoagulation/providers/warfarin/Pages/supplement-interactions.aspx.