Warfarin Protocol Initiated!

[Seaton]

And if 8 today and 7 for the following two days brings your INR in range, will they have you stay on 8, 7, 7? It just seems a bit weird to me.

From 8 today, they are actually dropping me to 6 for the next two days. But your suggestion of 7mg daily going forward and testing Thursday and again on Monday seems reasonable.

I will do as they say for now and confer with them on Thursday. Keen to get back in range.

*Am booked for an initial consult with their self-testing specialist, May 9.

 

[pellicle]

They've upped tonight's (Monday's) dose to 8mg. Told to take 6mg Tuesday/Wednesday.
Back in the clinic for bood draw/INR check Thursday.

Dopes

 

[Seaton]

Clinic blood draw today (Thursday) – INR now 1.4

New dosage schedule given:

• 6mg tonight
• 7mg Friday, Saturday, Sunday
• 6mg Monday
• Clinic INR test Tuesday

 

[LondonAndy]

Seems weird to prescribe 6mg tonight - INR is a bit low and needs increasing. I would be tempted to do 7mg tonight, Friday and Saturday, then drop to 6. With the next clinic test on Tuesday that also has the advantage that you can see if the 7mg for 3 days has made a sufficient difference, given that the test will be 3 days after dropping it back to 6mg.

 

[Protimenow]

I second Pellicle's post: 'Dopes.' These guys clearly don't have a clue.

My advice: go somewhere else. Even better, get your own meter ASAP, and start self-testing. There are folks here (Pellicle in particular) who can help you navigate your dosing.

You might have to find a doctor who can prescribe your warfarin and who trusts you to self manage and will write the prescriptions. But this HAS to be better than what these nimrods are telling (not asking...telling) you to do.

You don't want an INR of 1.4 -- and 1.4 today? Who knows if it dropped even lower than that during the past four days. It may even make sense to bridge for a few days until your INR is back above 2.0 (I hate bridging and I start my normal dose immediately after a procedure that required that I drop it, but I would NOT be comfortable if I had it below 2.0 for more than 5 or 6 days).

These clowns initially gave you things to look out for if your INR was too HIGH. They didn't mention things like strokes or pulmonary embolisms if your INR is low. Maybe they aren't concerned about low INRs in their patients. Maybe they don't even know. Or maybe they figure that if a patient dies from a stroke, or is severely disabled, it's no longer their concern because someone else will be handling this vegetable.

In any case, it'll probably take a few days to bring your INR back in range. Good luck during this period.

 

[Seaton]

Seems weird to prescribe 6mg tonight

Yes. That’s what I thought... but also half expected, considering how things have gone so far.

Have a self-testing interview with the clinic next Thursday. The clinic said don’t buy an INR meter until you’ve had this interview. Tempted to just buy the meter anyway rather than wait for their official go-ahead. I suspect the interview is to assess my capability to self-manage. (The meter may be eligible for a company discount if approval comes through the clinic - although I may be wrong about that.)

Taking a 7mg tonight is a temptation. Although I’m now wondering if I move into range by next Tuesday, will they then suggest dropping my dose again (like last time)? And thus we’ll be back where we started? Hmmm...

 

[Seaton]

There are folks here (Pellicle in particular) who can help you navigate your dosing.

Sound advice and one I have been following behind the scenes in preparation for getting my own CoaguChek® INRange soon. Pell’s been very helpful. As have you all.

but I would NOT be comfortable if I had it below 2.0 for more than 5 or 6 days

Yes, that’s my concern. I may contact them again tomorrow to discuss, especially considering I’m on no other anticoagulant at present, other than the out-of-range warfarin.

Good luck during this period.

 

[pellicle]

Hi

Taking a 7mg tonight is a temptation. Although I’m now wondering if I move into range by next Tuesday

it depends, but as you next identify:

, will they then suggest dropping my dose again (like last time)? And thus we’ll be back where we started? Hmmm...

they will ... its like people who always work overtime but dont write it up; it just leads management to think that they can push the person harder to "do more with less" (subject of many a mentoring session at my work over many decades of working in big bureaucratic organisations).

So my advice here is to exactly follow what they do, then when they are wrong (not certain, but I think quite likely) ask the following questions:

1. is my target INR 1.4 or 2.4?
2. is the purpose of taking warfarin my INR or some arbitrary mg per day dose? (hint: the intention to treat is only INR)
3. given the evidence why did you not move my dose up?
4. why are you alternating doses which are not even whole increments of pill sizes? (pill sizes are commonly 1, 3 and 5mg, but that depends on the brand you have; so the argument of "its for your convenience" is bull5h1t).

I don't expect good answers to these and I wouldn't press them because fundamentally they are not educated in this area, have no pharmacology knowledge (they are clinicians, so above warders but well below nurses and even doctors are like ¯\_(ツ)_/¯ warfarin is hard which it is if you don't know {which they should}).

The alternative (and I know one Britt who does this) is to lie, he does this because:

• he has ~10 years under his belt of self management
• he doesn't like arguing with them
• all he needs is to keep them happy
• he gets his prescriptions as needed from his GP and his strips as needed from the NHS
• they see the report "he's in range"; so all is happy

Best Wishes

 

[Protimenow]

Hi

it depends, but as you next identify:


they will ... its like people who always work overtime but dont write it up; it just leads management to think that they can push the person harder to "do more with less" (subject of many a mentoring session at my work over many decades of working in big bureaucratic organisations).

So my advice here is to exactly follow what they do, then when they are wrong (not certain, but I think quite likely) ask the following questions:

1. is my target INR 1.4 or 2.4?
2. is the purpose of taking warfarin my INR or some arbitrary mg per day dose? (hint: the intention to treat is only INR)
3. given the evidence why did you not move my dose up?
4. why are you alternating doses which are not even whole increments of pill sizes? (pill sizes are commonly 1, 3 and 5mg, but that depends on the brand you have; so the argument of "its for your convenience" is bull5h1t).

I don't expect good answers to these and I wouldn't press them because fundamentally they are not educated in this area, have no pharmacology knowledge (they are clinicians, so above warders but well below nurses and even doctors are like ¯\_(ツ)_/¯ warfarin is hard which it is if you don't know {which they should}).

The alternative (and I know one Britt who does this) is to lie, he does this because:

• he has ~10 years under his belt of self management
• he doesn't like arguing with them
• all he needs is to keep them happy
• he gets his prescriptions as needed from his GP and his strips as needed from the NHS
• they see the report "he's in range"; so all is happy

Best Wishes

I did the same thing that Pellicle describes:

When I was required to go to a 'coumadin clinic' about 12 years ago, I had already been self testing and self managing for about three years.

I answered the usual questions about change in diet and other stuff that my affect my INR, then they used a meter to test my INR.

Gee - it was always in range. I wonder why.

They didn't seem to believe me when I told them that I self test and self manage. These wizards referred to me as 'Mr. Consistent' because my INR was always within range. These wizards moved my testing to once weekly, to once every two weeks, to once monthly. It was when they wanted to test every two months that I'd had enough of their BS.

But for a while I kept them happy and let them THINK they had something to do with my consistent INR.

 

[pellicle]

Gee - it was always in range

LOL

generally speaking (to any reader) take this into account when you read that "some people are very stable"

... or their reported INR ...

 

[Chuck C]

I have to agree with the comments here that suggest your clinic managing your INR is screwy. In fact, I see no sign of competence at all.

Several days at 7mg led to INR of 1.3.

Increase dose to 8mg for two days, which results in an INR of 2.0, at the bottom end of your range.

Here comes the good part- now that you are in range, they decide that the proper adjustment is to reduce your dosage by about 40% and have you take 5mg per day and for good measure have you arbitrarily take a higher dosage of 6mg on Saturday and Sunday.

Anyone paying attention would not be the least bit surprised when your INR fell to 1.4 on the next test.

Their action plan after that was equally nonsensical.

You may have heard of the experiment in which blindfolded monkeys picked stocks by throwing darts at the financial pages of a newspaper. The monkeys beat the market, and many experts. Well, I think if you blindfolded a monkey and had him throw darts at a range of warfarin dosages, he would probably do better than this clinic at helping you stay in range.

Blindfolded Monkeys Pick Stocks

https://www.forbes.com/sites/rickferri/2012/12/20/any-monkey-can-beat-the-market/?sh=492486d5630a


As others have suggested, I would agree that the sooner you get your own meter and start self testing the better.

 

[pellicle]

Blindfolded Monkeys Pick Stocks

Gosh, I'd all but forgotten about that one.

Thanks for the reminder

 

[Jeff Lebowski]

My inr value losing altitude
On 27 March, after my aortic valve replacement surgery, my inr value gradually increased during the one-week hospital stay and reached the ideal value of 2.17 on 4 April.

On 9 April, my inr value was measured as 2.12, I was taking 5 mg Warfarin daily during this process.

I pay attention to my diet so as not to impair the effect of Warfarin. I avoid foods that increase clotting and I do not use alcohol and similar substances that thin the blood.

However, despite all this, as a result of the test I had done on 26 April, I saw that my inr value dropped to 1.74. I sent the test result to the doctor who performed my surgery, and he rearranged Warfarin to 7.5 mg 3 days a week and 5 mg for the remaining 4 days.

However, as a result of the test I had done today, I saw that my inr value decreased to 1.69. my doctor increased the daily dose to 7.5 mg. My doctor also told me that Warfarin can interact with meals, so it would be more convenient for me to take it at 03:00 pm

It has been 37 days since my surgery, I do not know what caused my inr value to slowly decrease while I was in the ideal inr range. These questions are constantly occupying my mind:

Is this a reaction of my body?

Even when we find the appropriate drug dose between the ideal inr range values, will I still always live with a doubt?

 

[pellicle]

Is this a reaction of my body?

Such is common in recovery. Intention to treat is only INR, so if it needs more steam, gently lean into it.

https://pubmed.ncbi.nlm.nih.gov/19336266/

will I still always live with a doubt?

No, we live with testing.

Reach out if you are attempting to self management (it's 10pm here, so goodnight for now)

 

[Chuck C]

It has been 37 days since my surgery, I do not know what caused my inr value to slowly decrease while I was in the ideal inr range.

It is very normal to gradually need a higher dose of warfarin duing the first 3 months that follow your surgery. The paper below describes this as decreasing warfarin sensitivity. It is exactly what I experienced, with my dosage of warfarin slowing increasing for several months after surgery. I linked a study below if you are interested.

So, this is normal and nothing to worry about. It sounds like they are reasonably guiding you and gradually increasing your dosage. The key is you want to be doing relatively frequent testing during this phase and certainly if you are below range, and make minor tweaks to dosage as needed, following the data from your INR testing.

"A steady increase in warfarin requirements was seen over the three months in patients with mechanical valves, bioprosthetic valves or valve repairs. The mean dose of warfarin increased by 26% while the mean INR decreased from 2.5 to 2.1"

https://pubmed.ncbi.nlm.nih.gov/19336266/

 

[Jeff Lebowski]

It is very normal to gradually need a higher dose of warfarin duing the first 3 months that follow your surgery. The paper below describes this as decreasing warfarin sensitivity. It is exactly what I experienced, with my dosage of warfarin slowing increasing for several months after surgery. I linked a study below if you are interested.

So, this is normal and nothing to worry about. It sounds like they are reasonably guiding you and gradually increasing your dosage. The key is you want to be doing relatively frequent testing during this phase and certainly if you are below range, and make minor tweaks to dosage as needed, following the data from your INR testing.

"A steady increase in warfarin requirements was seen over the three months in patients with mechanical valves, bioprosthetic valves or valve repairs. The mean dose of warfarin increased by 26% while the mean INR decreased from 2.5 to 2.1"

https://pubmed.ncbi.nlm.nih.gov/19336266/

Chuck, thank you very much. It turns out I was worrying unnecessarily.

 

[Protimenow]

There was a time when doctors wouldn't even prescribe a meter for 3 (or is it 6) months after surgery. This is for the reasons listed above -- your dosage won't be stable until your body heals a bit more.

FWIS - diet may not be as important as it was once thought to be.

 

[pellicle]

Good morning

Even when we find the appropriate drug dose between the ideal inr range values

to address this point firstly:

I didn't see dose thus any change in dose between 09/4 and 04/5 ... was there?
If not why was there not? I mean while its true that a modern bi-leaflet valve can tolerate dips below (indeed the On-X markets directly to that point) but weeks of below 1.89 (the average in the On-X trial) is not appropriate. Heck I know people who will reach for the Heparins (Lovenox) as soon as it even reaches 1.9

There is no perfect dose only a "perfect INR range"; which even that is subject to alterations based on the compromise of your health condition.

Look my own dose graph here:

you will see my highs topped out at under 3.5 and my lows were in the main above 2.0

you will also see I was "on the same dose (but INR varied somewhat) for multiple stretches ... not all of which were 6.5mg

This is why we test ... if you do not test and adjust appropriately then you will join the statistics of "the general population".

Why test at all if you aren't going to adjust?

Equally don't over adjust ...

You may ask "how did I know how much to change my dose" ... well I know that because of my data model, others "feel its right" due to pure experience.

Best wishes

 

[Protimenow]

I usually change my dose by .5 at a time. This usually works for me....I don't mind going slightly below 4.0 - I can adjust to bring it down. What I DO mind is somehow going below 2.0.

Small dosage adjustments have worked well for me.

 

[Jeff Lebowski]

I didn't see dose thus any change in dose between 09/4 and 04/5 ... was there?

My warfarin dose changes are not included in the table I prepared (but it is a good idea, I will add it to the table). However, I have already mentioned my warfarin dose changes in my post.
Best regards