On-X Aortic Heart Valves: Safer with Less Warfarin On-X Aortic Heart Valves: Safer with Less Warfarin

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How far into range are you comfortable with?

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  • How far into range are you comfortable with?

    Random question... we're doing mom's testing at home now (thanks to the help of a bunch of nice folks here) and the last 3 Fridays she's been at 2.1 (2 - 3 is her target range). She takes 5mg every day except Tuesday and Thursday where she does 2.5mg. I'd like to see her a little more into the middle of the range and asked the clinic about going to 5mg every day BUT Thursday and they said no because she's in range so why mess with it. We're testing every Friday so I don't worry much about her dropping and I don't want to see it go high but I feel like that extra 2.5mg in the week could help get her closer to the middle.

    What say you?
    Daughter of mom (73) w/ MV stenosis, severe prolapse/regurg, a-fib. LA enlarged, LV normal; 1997 - Balloon valvuloplasty - Dr. Pichard -
    Wash. Heart Ctr; 11/00 - Eval by Dr. Hobbs at CCF for MVR. Determined MVR not needed at that time; 12/10 - Eval by Drs. Hobbs and Lytle at CCF for MVR "come back and see us in 6 mths"

  • #2
    I agree with the lab. So long as she is in range I'd leave it alone.
    FWIW:
    INR=1.0 .......PT in seconds=12....... Normal person not on ACT
    INR=2.1 ...... PT in seconds=22........Her current testing
    INR=2.5 .......PT in seconds=26........ Mid-point of her rang

    Note that both 2.1 or 2.5 INR have similar clotting times(22 vs 26).....and an INR at the lower end may help to reduce bruising which can be a problem for senior.
    Last edited by dick0236; March 10th, 2017, 11:34 AM.
    Starr-Edwards mechanical AVR 1967 at age 31.....University of Kentucky Med. Ctr., Drs. Richard Wood & Gordon Danielson surgeons. No surgery (heart or otherwise) since. On Warfarin ACT since surgery with no diet, lifestyle, or activity restrictions....and I live one day at a time.

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    • #3
      Dick makes some very valid points, and of course for an older person bruising may indeed be an issue, particularly if they have delicate skin or are clumsy. Speaking for myself, when I am close to either end of my range (2.5 to 3.5) I tend to make a one-off "course correcting dose" and test again in about 3 days time to see what effect it had. So if I was close to the bottom, I would take a little extra Warfarin. This is because I like to have a margin of error - I find that if I get a cold the first sign is a significant drop (more than 0.5) in my INR. If the one-off dose has not made much difference I might take another one-off dose, and if over the next couple of weeks my INR drops back down again I would consider revising my daily doses.
      Mechanical aortic valve replacement, CABG x 1 and pacemaker, Sept 2014, at age 49. Insulin dependent diabetic.

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      • #4
        Hi

        Originally posted by watson524 View Post
        Random question... we're doing mom's testing at home now (thanks to the help of a bunch of nice folks here) and the last 3 Fridays she's been at 2.1 (2 - 3 is her target range).
        here's the thing ... I don't really like "range" I like the alternative view of "target INR" ... which in her case is probably 2.5

        Why? Well it comes down my preference that you aim for the center of the target, not "aim to be on paper". If you're hitting the target with where you're aiming for then you don't adjust your aim point till you've evaluated things (then you can work out your "grouping"


        She takes 5mg every day except Tuesday and Thursday where she does 2.5mg.
        I"m also not fond of this approach either ... because it stems from this:

        ... but I feel like that extra 2.5mg in the week could help get her closer to the middle.
        Its to me not even old school thinking, its weird school thinking. If you accept that doses should be thought about in weeks, well why not take your entire weeks dose on monday, and save yourself to remember needing to take it every day?

        Oh ... right, of course that'd be silly ... the doses must be something more even right? So lets take the example of 49mg per week. Does it then make more sense to take 25mg on Monday and 24mg on Thursday?

        Of course ... that's still not even.

        So why then is it "ok" to take 5 mg on every day except Tuesday and Thursday? Is it like a "metabolism holidy"? Because you eat Fish on Fridays?

        Which day do you measure on? A day after a series of 5's or after the 2.5?

        I've never heard of this in Australia (this weekly dose stuff) but to me the only way to actually know what the hell is happening is to be consistent with your doses. As I wrote on my blog post the variation of dose must result in a variaion of how the processes are reacting, in the simplest possible view of things a model (which is not accurate but demonstrates a point) could look like this:


        Now of course the INR isn't going to be exactly like that for the same reasons that if you have 5mg every day the INR will not be like a flatline either. It will vary up and down due to variances in Metabolism. IF you happen to time a "increase" in dose with an increase in metabolism it may go higher (same too for a decrease).

        Imagine two kids jumping on a trampoline. Same scenario. So I'd be tending to try to even it out ... say 4.25mg daily? For instance (depending on your brand) there is a 4mg tablet and a 1mg tablet ... not too hard.

        Myself I have a stock of 1, 3 and 5mg tablets which I use to make up my dose (which is 7mg daily aothough some weeks I drop back to 6.5mg daily) You can see that in one of my INR charts that I've published here.

        However where I would take the side of dick0236 is that you just don't have any data , you don't have any history, you don't have any way to even have a go at deciding if putting a dose up will push you above range.

        Having said that unless your mother has a propensity for bleeds (and she's on it for clots right?) then its likely that an INR of 3 or even 3.5 (in theory out of range) will not be harmful.

        But without good baseline data with which to make informed decisions you're just guessing ... not something I recommend.

        If you want to gather better data PM me and I'll help you put together a basis for gathering data and having a better idea. It does take time to gather enough data to be significant, at least a few months. So its not instant. However (for myself) I have been on this drug for 5 years already and anticipate being on it for more years to come. So I've got time.

        Some reading if you want

        http://cjeastwd.blogspot.com/2014/05...ocks-dose.html

        http://cjeastwd.blogspot.com/2014/09...ng-my-inr.html

        There is a lot in there ... so feel free to ask questions

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        • #5
          watson524 I second this motion as being a good approach

          Originally posted by LondonAndy View Post
          .. I tend to make a one-off "course correcting dose" and test again in about 3 days time to see what effect it had.
          but as Andy implies he knows his cycles meaning he has a history of data to refer to ( LondonAndy no?)

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          • #6
            Originally posted by pellicle View Post
            watson524 I second this motion as being a good approach



            but as Andy implies he knows his cycles meaning he has a history of data to refer to ( LondonAndy no?)
            Yes, I have 2.5 years of weekly testing to refer to now, but I started experimenting quite early on with what effect an extra 1mg or 2mg would have on my INR, so perhaps I was a little cavalier at the start but Watso524 asked about where we would aim to be, so I was answering for what I would do. Having my own meter to test my INR at home gave me the confidence to try small adjustments, and to test more frequently to see results, safe in the knowledge that if I made a mess of it (my INR level) I could pop along to my hospital anti-coagulation clinic for professional guidance if needed and "free treatment" (at the point of delivery anyway) thanks to our NHS. This also means that I can get the test strips free of charge as needed too, so experimenting is perhaps an easier thing for me to do than those who have to pay for everything.
            Mechanical aortic valve replacement, CABG x 1 and pacemaker, Sept 2014, at age 49. Insulin dependent diabetic.

            Comment


            • #7
              Mom's been on ACT for almost 35 years but it's only in the last 2 months that we've gone to home testing on a weekly basis. Prior to that she was steady and her doctor had her get vein draws monthly. I never agreed with his methods but for the most part, she was in range I'd say 90+% of the tests.... my problem being who knew what was going on in between tests, a whole other topic. Hence part of the reason for the push for home testing on a weekly basis. She bruises very very easily and always has and now we have the added complication of onion skin and she's very prone to skin tears especially as she hits her hands on door ways going through in her wheel chair when she's moving herself around. I've used more skin glue that I can shake a stick at however, she doesn't have "bleeding events". She doesn't really bleed much more than when I would get a similar tear.

              Being at 30mg / week I believe they just went with the 5/2.5 because that's what we had on hand. If I tried to even it out more it'd be a 4 and 1mg pill supply and do 4mg on say Sun, Tuesday, Thursday and then 4.5 on the other 4 days. We currently test her on Fridays about noon (she takes her dose at 8pm) and she has 2.5mg doses on Tuesday and Thursday so maybe we're just seeing the slightly "low" because it's after a 2.5mg dose.
              Daughter of mom (73) w/ MV stenosis, severe prolapse/regurg, a-fib. LA enlarged, LV normal; 1997 - Balloon valvuloplasty - Dr. Pichard -
              Wash. Heart Ctr; 11/00 - Eval by Dr. Hobbs at CCF for MVR. Determined MVR not needed at that time; 12/10 - Eval by Drs. Hobbs and Lytle at CCF for MVR "come back and see us in 6 mths"

              Comment


              • #8
                Hi

                Originally posted by LondonAndy View Post
                ... but I started experimenting quite early on with what effect an extra 1mg or 2mg would have on my INR, so perhaps I was a little cavalier at the start
                no, I think that was entirely appropriate and (what follows is the really important bit) because you documented it (not just gut feeling'd it) you learned and have more to work with. I suggest watson524 does exactly that (and perhaps more)


                but Watso524 asked about where we would aim to be, so I was answering for what I would do.
                I was not criticising you I was using you as an exemplar.

                This also means that I can get the test strips free of charge as needed too, so experimenting is perhaps an easier thing for me to do than those who have to pay for everything.
                shit that would be nice ... still my experiments are only $5 a pop ... so spread over a few weeks is not so bad as investments go. I did daily measurements for a while and came to the conclusion that half weekly was good enough.

                Sort of like how 128Kbits/sec MP3 is good enough for most music and a lot less data than 44.1Khz 16bit (which is full blown CD)

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                • #9
                  Originally posted by watson524 View Post
                  Being at 30mg / week I believe they just went with the 5/2.5 because that's what we had on hand. If I tried to even it out more it'd be a 4 and 1mg pill supply and do 4mg on say Sun, Tuesday, Thursday and then 4.5 on the other 4 days.
                  I have noticed some people in different countries refer to different pill sizes. Here in the UK we are given a supply of 1mg, 3mg and 5mg, so used in combination it is easy to make any dose.

                  And I definitely agree with you about the value of self-testing. A lot can happen between monthly draws at a clinic, and also a finger prick is much easier than having blood taken from the same vein or two every time.
                  Mechanical aortic valve replacement, CABG x 1 and pacemaker, Sept 2014, at age 49. Insulin dependent diabetic.

                  Comment


                  • #10
                    I like the fact that your Mom's INR is so stable....having 3 tests in a row reading at 2.1 is very good.
                    But, for me, I prefer my INR a bit higher than that so I have some wiggle room for when I indulge in broccoli, brussel sprouts, spinach salad, etc.
                    I have the Coaguchek XS meter and have home tested for almost 10 years, I have all my results written down and feel safest when my INR is closer to 3.0
                    If some sort of world disaster happens and I miss a daily dose, my INR won't hit bottom so quickly and I will still be protected.

                    My dose is 16 - 17 mg per WEEK and I can affect my INR result with a very small dose change of 1 mg per week.....no big changes necessary, in my case.
                    [COLOR=blue]BAV-Aortic Stenosis...AVR Oct 11, 2005 / St.Jude Regent mechanical 21mm
                    INR Home testing since 2007 with Coaguchek XS...Self-Dosing[/COLOR]
                    [COLOR=red]"Caution: I may have been in contact with Nuts"[/COLOR]

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                    • #11
                      I prefer to keep my INR @ 2.5 (Cardio's recommended range is 2 - 3). My dosages are 16-17 mg / day === roughly 115 mg / week.
                      I seem to have very high metabolism and am extremely active. I home-test twice a week.
                      21mm On-X mechanical aortic valve replacement (SN: 4476814), (Ref: ONXACE) by Dr. William A. Cooper @ Wellstar Kennestone Hospital, Marietta, GA, USA on 6/21/2016

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                      • #12
                        Thanks for all the advice. We're staying where she's at dosage-wise. 2 weeks ago when she only had PT one day vs two, her reading went up to 2.3 and I thought that makes sense because she exercised less. Last week it was the same so maybe that theory is only roughly baked. Building a database of numbers tho where I'm tracking readings each week plus anything I can think of that's "out of norm" so I'll be able to compare and whatnot.
                        Daughter of mom (73) w/ MV stenosis, severe prolapse/regurg, a-fib. LA enlarged, LV normal; 1997 - Balloon valvuloplasty - Dr. Pichard -
                        Wash. Heart Ctr; 11/00 - Eval by Dr. Hobbs at CCF for MVR. Determined MVR not needed at that time; 12/10 - Eval by Drs. Hobbs and Lytle at CCF for MVR "come back and see us in 6 mths"

                        Comment

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