Keeping stable INR - advice please

[GeorgeM]

I had a mechanical aortic valve and root repair done 10 weeks ago, and just had the all clear from my cardio.

Since having my op, my INR level has been tested every week and it has varied from 1.8 up to 4.3. I am taking Warfarin doses in the range 1.5 - 3 mg daily.

Can anyone offer advice on how best to keep my INR level stable (my target is 3 - 3.5) ?

At present I get my INR tested at a local clinic, but I am arranging to get a self-testing kit to monitor my own INR level, so that I can reduce the frequency of clinic visits.

It would be great to resolve this one as clinic visits can be extremely time consuming !!

Best Wishes

George Montgomery

 

[kbheart]

I try to keep my eating pretty consistent (a little green vegetables every day). And I do the same with my medications. I take the same vitamins every day. Mine has gone up and down because of other prescription medications they've had me try. Also, I just read that menthol cough drops can affect your INR. Here's the link:
http://www.ncbi.nlm.nih.gov/entrez/...ve&db=PubMed&list_uids=15644472&dopt=Abstract
Since my surgery, I've used a lot less over the counter medications since I want to keep it as simple as possible. But it is never simple!
I'm with you, it would be nice to get a home monitor.

 

[Cooker]

I try to keep my eating pretty consistent (a little green vegetables every day). And I do the same with my medications. I take the same vitamins every day

The key is being consistant. I eat anything I want trying not to binge (much ). It took three months for my INR to settle down but I have been in range for nearly a year now. That may change but so far so good.

Good luck.

Tom

 

[Rich]

Hi George,
As others have stated be consistent.
Many things can and probably will affect your INR.
Vegetables with high amounts of Vit K.
Alcohol cosumption.
Medications.
Activity level.
That doesn't mean you have to be a fanatic about any of these things, just try and be fairly consistent.
Rich

 

[Ross]

George first of all, it's nearly impossible to maintain a range like 3.0 to 3.5. That alone tells me that whoever is managing your Coumadin, doesn't understand the drug. 2.5 to 3.5 should be the true range and honestly, most of us consider anything between 2.0 and 4.0 to be acceptable.

Can you post your daily dosage and how often they are changing you dose on you? I'm betting anything that they have you seesawing because of lack of understanding. Also, any other meds that you take.

At 10 weeks, you should be pretty well situated and very close to stable.

Eat the way you like to eat. Do not deviate from your normal diet. If you like lots of greens, eat them. Your dose can be adjusted for this, then try to remain as consistent as possible. I'm anything but consistent and still my INR is pretty rock stable. If your very active your INR is going to drop as you recover.

 

[GeorgeM]

Thanks all for your advice. Being consistent looks to be what I need to follow.

But say if I haven't had any alcohol in a given week, then get tested, and then have some alcohol will that decrease my INR ?

(I'm talking about a glass or two of wine with a meal - not getting sloshed !)

If so does that mean if I want to drink, I have to drink at the same rate each week ?

Ross - I am taking daily 5 mg Bisoprolol (beta blocker) and 1 to 3 mg Warfarin (dose is adjusted weekly or bi-weekly by clinic with INR result). When I was tested two weeks back my INR was 3.1 but today it was down to 1.9 (I had been taking 2.5 mg Warfarin daily in the period in between), and been eating steadily.

Also would exercise like running affect my INR ? (planning to re-start running soon)

Many Thanks

George

 

[Ross]

It's not you George, it's the person managing your INR. They should never have changed you for an INR of 3.1. Whatever that dose was, is your sweet spot, I'll bet on it! Let me guess, they got 3.1 and lowered your dose and then you ended up at 1.9, now they want to increase it again? If it's between 2.5 and 3.5 there is no need for them to change a thing. If they insist on doing so, find another clinic to go to. they aren't giving you enough time to stabilze before they change your dose again. 3mg per day seems to be your dose. Don't be surprised if you have to up it some with increased activity.

The alcohol--You most likely won't see any change. Just be careful because if you have or are developing an ulcer, it could bleed and it's very hard to stop a GI bleed.

 

[catwoman]

George:

As you return to your normal lifestyle, you will probably be more active and eating more. An increase in activity will circulate your blood more frequently through your liver, which metabolizes warfarin, requiring an increase in your warfarin dose to maintain the same INR.
At the same time, you will be eating more normally. There is vitamin K in oils and dark green vegetables. When you resume eating these, you will need more warfarin to counteract the increase in vitamin K via your foods.

Here's a pdf version of the prescribing leaflet for Coumadin.

http://www.bms.com/cgi-bin/anybin.pl?sql=select PPI from TB_PRODUCT_PPI where PPI_SEQ=91&key=PPI

Don't nickel and dime the veggies, just pay attention and be fairly consistent in your eating habits. I've found that I don't have to eat my dark green veggies every day; I may have a huge amount one day, then skip a day, then return to a more "normal" portion after that.

If you don't eat much dark green veggies and are a couch potato, then suddenly eat broccoli-beef stir fry every day for a week and jog every day, your INR will drop.

I have learned more at this website about living with a mechanical heart valve and taking warfarin than anywhere else. My PCP is very knowledgeable about warfarin, but I don't have access to him every day like I do vr.com.

 

[GeorgeM]

Ross & Ellen

Many thanks for your advice. Certainly having online access to VR.com has been a wonderful support to me (and I'm sure to many others).

I'm back at the clinic Tuesday so we'll see what the INR is then.

Best Wishes

George

 

[ALCapshaw2]

Welcome George,

I'm wondering why your Doc wants your INR between 3.0 and 3.5 for a mechanical Aortic Valve. Have you had any clotting issues such as a stroke or TIA's (Transcient Ischemic Attacks)? The usual guideline for AVR is 2.0 to 3.0.

Mitral Valve recipients are generally advised to maintain an INR of 2.5 to 3.5.

Note that the 'Safe Range' for INR is generally considered to be from 2.0 to 5.0. Below 2.0, the risk of Stroke goes up and above 5.0 the risk of Bleeding Events goes up (although we have had several members report INR's of even 8.0 with NO bleeding).

One of our favorite sayings is that "It is easier to replace Blood Cells than Brain Cells" and for that reason, many prefer to maintain their INR on the high side of their recommended range.

Be aware that metabolism (and therefore Exercise) can cause your INR to drop so as you become more active, you may need to MODERATELY increase your dosage. SMALL changes, no more often than once a week should keep you stable.

See Al Lodwick's website www.warfarinfo.com and buy his Dosing Guide (online, $5, a GREAT GUIDE at a great value).

'AL Capshaw'

 

[GeorgeM]

Al

My surgeon set the range 3 - 3.5 and the clinic have followed that. However I have read other posts here stating that a range of 2.5 - 3.5 is more practical and manageable from a dosing viewpoint.

I don't suffer from TIAs (at least not so far).

Your advice that it's better to have your INR a bit on the high side seems very wise to me.

To make the small dosage changes you suggest would imply home testing. Is that what you do ?

Thanks for your advice.

Best Wishes

George

 

[catwoman]

George:

It's more difficult to stay in a range with a variance of 0.5 than 1.0. That's why some have questioned the 3.0-3.5 range you have been given.

The range for aortic valves is usually 2.0-3.0. Some medical professionals have recommended 2.5-3.5 for aortics. Mitral valvers are generally told to keep their range 2.5-3.5, or sometimes 3.0-4.0. There is a greater risk of clots with mitral valves than aortics.
.

 

[Ross]

George a single test can vary by as much as .5, so the narrow window is impracticle and anyone trying to dose it should know better.

 

[Georgia]

George, as others have said, changing your dosage all the time is causing the problem, not correcting it. Because it takes the body 72 hours to completely metabolize a dose of warfarin, your tests won't even reflect your current dosage if it's changed too often and if you're tested too often.

I've found that exercise changes affect my inr more than foods (unless I really pig out on broccoli - as I did on Easter). When we take a two day road trip, I consciously (and conscienctiously [sp?]) eat extra greens.

The other thing you must watch out for is protein/energy bars and drinks. And Ensure. And anything that's promoted as "healthy" food additives. Read your labels carefully - they're usually loaded with Vitamin K.

Please check Al Lodwick's site. You need to become an expert quickly, as the medical professionals generally are ignorant of how to manage warfarin in younger, active individuals.

 

[aussigal]

Al



To make the small dosage changes you suggest would imply home testing. Is that what you do ?



George

This is how I manage a 'small change'...when my Doc orders me to reduce or increase my dose by 1mg per dose I actually do this in 2 stages over 2 weeks increasing 0.5mg per dose for a week,. then have an INR test...and repeat the dose-change next week to achieve the 1mg he advised only if I am still not in-range...this way I avoid the yo-yo effect! I dont home-test, and my Doc and nurse have come to expect me to make small adjustments to my dose and are happy as long as I stay in-range. Also , I dont get tested more often than once a week so as to fully allow my system to adjust to the new dose.

 

[GeorgeM]

Thanks Georgia & Aussigal

I like the approach of making small dosage changes rather than bigger ones to avoid INR swings -let's see if I can achieve that !

Best Wishes

George

 

[Ross]

Thanks Georgia & Aussigal

I like the approach of making small dosage changes rather than bigger ones to avoid INR swings -let's see if I can achieve that !

Best Wishes

George

Once you get the hang of it, it really is simple. It's just that on one side, your trusting people with your care to know better and they may NOT, then you come to a place like this and we tell you something different, but it works!

I know my lab was doing the same thing to me as they are you. I got tired of it after about 2 months and still not being stable and switched to a finger stick clinic and Al Lodwicks advise. I was in range in 2 weeks and pretty solidly at that.

 

[OldNick]

I haven't been on this forum in quite some time, but, with mechanical St. Jude Aortic and Mitral valves since 1993, I have been adjusting my medication, with the agreement of my PCP and Card, for many years. I have found that small changes in dosage are a must, and tracking is best done in terms of total mg per week. I use combinations of 2.5 and 3.0mg tablets to give the desired weekly dose, presently at 18mg/wk. I have been using my PCP to draw the blood sample and send it to Quest Diagnostics in Nashville, the same lab used by my Cardiologist. My current frustration is that I have had two lost samples, one this week. This makes me consider home sampling. Since I am on Medicare, from what I read, the expense might be reimbursible. My surgeon set my target INR level as 3 to 4 because of the Mitral valve, which has a lower flow velocity and more possibility of clotting.

 

[Magic8Ball]

I have read somewhere that if you document what you eat over a two week period you will find that you tend to eat/drink the same amount of stuff without really trying to....not done it myself.

I asked loads of questions when i first started 6+ months ago and things have settled way down. I'm happy with my range 2.5-3.5 and seem to stay around 2.6 most tests (weekly home testing), if i drop close to 2 which i have on occasion i just take an extra 1mg that day and then return to my normal dosing of 5mg a day.

As for the booze i know its a touchy subject on this forum with some fairly strong views about its use with warafin but i tend to have two glasses of wine probably 3 times a week. I have on 3 occasions drank 4 glasses of wine (1 accidental 2 on purpose) and have tested afterwards and it made bugger all difference to my INR...but doing that daily would i'd expect.

As for your comment about drinking lowering your INR i have been told that it Raises your INR so i guess we could both do with some help on that one....Anyone else know which way it goes up/down with regards to alcohol?

For example, I'm off out tonight to a charity function, i'll test my blood before i go and if i'm around 2.3 to 2.6 i will have two, three or even four glasses of wine, depending how i feel but no more than that. If i test 3 or higher then i'd just have one glass with my meal. When i get home i'll make sure i drink water to ensure i don't get dehydrated in the night.

I have found this works for me, you need to find what works for you.

I'm also a big bloke so my alcohol tolerance was very high before surgery so you just have to find your level, having a home testing kit helps you find this level easily.

 

[Ross]

It can go just about anyway with alcohol. Some up, some down, some no difference. I can drink just about all I want and have no change.