Course of Action for INR Correction?

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Perrster

Dear Allodwick,

I am wondering what you recommend as a course of action to take to analyze what causes one's Protime to bounce up and down? Is there a recommended process one can follow? What do you [vr.comer's] do?
How much danger is there with this yo-yo effect?

I actually feel pretty darn good. I exercise at least 4 days/week, and maintain a fairly consistent diet. I don't have any bleeding problems or any other side-effects that I can tell. The yo-yo doesn't seem to get in the way of anything, except to cause me frequent PT tests. So, all I want for Christmas is to get back to the stability that I had and only have monthly tests.

Here's what's happening:
- October INR of 2.1 (adjusted intake*)
- 3.8 in mid November (adjusted again*)
- 4.0 December 7 (adjusted intake*)
- test again December 19
*Each adjustment is based on the recommendation of my local Coumadin Clinic nurse (I don't trust my own judgement for any medications).

I take 2.5 and 5.0 every other day, making adjustments as recommended.

Prior readings were:
August 3.2
August 2.9
September 3.3
Early October 3.4

I got that nasty Bronchitis in mid-October and took a fairly heavy dose of Amoxicillin for about 1-1/2 weeks. I think that caused the "INR spike" to 3.8.
I haven't been "right" since!

Living on Warfarin, I'm well aware of dietary consistency. Mentally, I am trying to let this be and not worry about it. I know some people here are tested every couple of weeks. Perhaps this IS normal? I just want to win this game and not have to be tested so damn often! My veins are getting harder for the nurse to hit. Last time she scored a 3-pointer on me!!!

Should I keep anally accurate records of every sneeze, and ....? Do I write down every morsel of food I put in my mouth? Does caffeine affect INR? I have been cutting my intake and will soon be cold turkey of all coffee. Such a sin for a young-old Swede! Nevertheless, not that good for the heart.

Thanks for the support and Happy Holidays to all my vr.com friends.
 
Perry,
Your numbers look pretty typical and nothing to be much concerned about. I would not try to keep accurate records. There are too many factors that can affect the INR to ever figure every one out.
As I have written before, I rarely get concerned about an INR under 5.0. I make slight adjustments, but do not get very concerned. I rarely test more than once per week. There has to be some serious problem to make me change this. The adjustments I make for INRs between 1.5 and 5.0 are almost always up or down by the equivalent of one day's warfarin dose per week. (Example: if you are taking 35 mg/wk and need to go up, I make it 40 mg/wk. using 1.5 tablets on Monday and Friday.)
Antibiotics can affect the INR. I think that some people do not absorb them well. This kills the bacteria in the intestinal tract. They produce vitamin K ... But just as important, the antibiotic is a marker for a person who is not feeling well. This can translate into decreased activity (decreased metabolism of warfarin) or decreased food intake (less vitamin K ...) If your warfarin dosing person reacts aggressively to the small, probably temporary, changes in the INR caused by these (or similar) reasons, it can take several weeks to get back to the desired INR range. My solution is to hold one day's dose and then go back to the regular dose. This usually keeps things pretty smooth.
To keep track of what doses of warfarin have been working and not working print out a chart for yourself at
http://www.warfarinfo.com/monitoringgraph.htm
Take this to your appointments. It readily will show how each dose did.
 
Hi Perry-

My husband Joe has been on Coumadin for 24 years and he knows that it always bounces around. He doesn't worry about it, he just lets the doctors take all the responsibility for the INR corrections, that's what they get the BIG bucks for! He has a lab and doctors that he trusts and who know what they're doing.

Just make sure to always ask what your INR is so you know that it's close to being in range.

There have been some times when Joe's has been unstable and usually during taking antibiotics as you've found out. But eventually with minor corrections it becomes more stable again.

When it fluctuates, the corrections made are in small increments so the INR doesn't ying and yang, and Joe might have to be tested more frequently during that period of time.

By the way, as to vein scarring, if anyone would have it it would be Joe, and he does, however, the lab is ALWAYS able to take a blood sample even with the scarring, that's what THEY get the BIG bucks for! So after 24 years of blood tests, no problemo. Oh they complain sometimes, but are always able to do their thing.

The best things that you can do for yourself are to find someone you trust to do this work, let them do it, double check by asking for the INR level, take your medication at the same time every day and in between times, forget about your Coumadin.

Go, enjoy life and have a wonderful holiday season.
 
My two cents......

My two cents......

Hi Perry

It is my understanding that with dual valves you would be best served to remain in the upper limits on the therapeutic range. Have read that a 4.0 INR would be safer under those circumstances. You may want to inquire. But, affaird most will not agree with and INR of 4.0. Al may beable to shed some light on this.

Believe me, have been on the roller costar ride. My former Coumadin nurse at my hematologist office adjusted me everytime I went in. If there was a concern....was told that adjustments by the hemotoligists protocol. All of their patients are adjusted the same. Well, you I and know Coumadin is individualized.

Target range is 3.0 -3.5 for my mitral valve. I am more comfortable at 3.5 - 4.0.

Anyway, what do you think the result was from the constant adjustments?? Up and down up and down for almost two years. There were times when I ran 2-3 times a week! She would adjust me if I were 3.4, down.... afraid I would exceed 3.5 which is still very safe. Finally, I said why don't we just leave it alone and see what happens. Poof.... I leveled off and was regulated.

Depending upon activity level and heat I have the tendency to either be on a straight 6MG daily or 6-1/2. Oh, and the alternating doses throughout the week ended up making me more unregulated! There was an article written on this somewhere. On how a consistent dose keeps you more stable.

When you become tired and worn from running to the Coumadin clinic constantly.... time to put your foot down! Condierer home testing Perry. It's really wonderul.

Keep us posted.
PS. Antibiotics and OTC cold meds tend to slightly lower my INR. I have been tracking this now since my MVR.
 
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Thanks!

Thanks!

I really appreciate all your responses. I thought I was committing a mortal sin with an INR that goes out of the therapeutic 2.5 to 3.5 range!

I shall try to follow your advice Nancy. I appreciate knowing Joe's scenario. Anybody that has put up with this for 24 years is a saint!

Nancy and Gina, I have fully put my trust in my Coumadin clinic. January 2002 will be my first full year under their care. (I don't think I'd qualify for a hometest device as I drive right by the clinic every day. Also my health club is right next door and affiliated with the hospital where the Coumadin clinic is located).

MATXR, thanks for that link. I've already downloaded the UserGuidePDF and should learn something from it.

And Allodwick, thanks as always for you response. I will start to use the chart you recommended. The clinic is very good on communicating results to me with next day follow up.

Cheers to a great holiday!
 
INR Chart

INR Chart

Hey Everybody,

I have a really neat INR chart that my son made for me. I tried to copy and paste it here, but it wouldn?t cooperate. If anyone wants a copy just ask, my e-mail address is. [email protected] It?s the chart I use to fax my results to my cardiologist. Mine is a little different that Al?s, mine shows your daily doses with a place for your INR results & comments each week.

Perry, when I stopped being so paranoid about being exactly between 2.5 & 3.5, my INR levels became much more regular. I do make a note of things I?ve done that I know affect my INR on the chart. It helps you understand why you were high or low when you look back through your results. Very interesting looking back through the charts of the last two years of my life with coumadin.

Rain
 
Let me throw in my husbands' two cents!

He has been on warfarin since May. They have ALWAYS had a problem, until three weeks ago, when he decided to take things into his own hands. He has his pills in many size doses, from 2.5's up to 10's. He put himself on a regular, every day dosage of 8.75, having to break one of the tiny pills in half. His INR has been perfect the last 5 tests, so now he only has to go every two weeks. So, I can tell you that I really buy into the regular dosage, regular results. Just a comment!
 
Your All Hired!

Your All Hired!

MBerge4527, Rain, Gina, Nancy (and St. Joe!), MATXR, and Al:

Thank you all again for your great comments. You've made me feel less stressed about my fluctuating INR's. At least I know the yo-yo effect isn't going to kill me. My Protime Clinic nurse might, but that is another situation I'll just have to deal with. If she weren't so cute...

Did I wish you all a Happy Holiday?!

p.s. Rain: I need the Excel version of the chart. I don't use Word Perfect.
 
warfarin

warfarin

my inr has also been up and down and i just started to take doses as i think are best. i am takin 7.5 for 2 days and then 5.0 for one day and so on. my # was 1.64 after being about 3.7. i was put on 5.0 daily with 7.5 once a week and it went way down. my regular doc was out so a sub prescribed this and then said take 5.0 daily with 7.5 2x per week. i decided as above on my own and will get checked again 2 week. any thoughts.

I got an aortic carbomedics valve and root May 8th 2001. Thanks
 
Hi Robt Z-

Take care dosing it yourself, unless you're well versed in Coumadin. I think there's a lag time between what you take and when it affects you. That's why they string out the increases instead of all in a row, so you don't get a major spike or start yinging and yanging which can get hard to control. They do it gradually. Hopefully allodwick will see your post and talk a little more sense than I am.

My husband has been on it for 25 years and that's how they seem to adjust it, no major swings, just slow and easy. It's worked quite well for him.
 
It is always a concern for me when someone gets their warfarin dose adjusted when their INR is 3.7. That is so close to the desired range that I wonder what the person's thinking was when they adjust that dose.
My rule of thumb is to adjust up or down by the equivalent of one day's worth of warfarin over the course of a week.

Example: S M T W T F S
5 5 5 5 5 5 5 and the INR is too low change to

S M T W T F S
5 7.5 5 5 5 7.5 5
or if the INR needed to go down from 5 mg/day.

S M T W T F S
5 2.5 5 5 5 2.5 5
Because warfarin does not work directly, but slows the production of clotting factors there is about a 3 day lag between when a dose is adjusted and when the results show up on the INR, the next check should be made in about one week. If you check more often, you are adjusting doses on the basis of an incomplete effect of the last adjustment. You then become a puppy chasing its tail - almost no chance of success it stabilizing a warfarin dose.
 
I self monitor (home test) and regulate myself. This was after 2 years of learning the ropes with the assistance of a hematologist.

Afterwards, my cardiologist prescribed the home unit and said talk to his lab tech about regulation because he is not as versed. Well...2 minuets into my conversation realized that she had no idea what she was talking about.

Back to my hematologist, his nurse insisted on alternating doses throughout the week. I was all over the place. Then I would get .01 out of range and she would change it again. How can one stabilize under those circumstances? Impossible.

There was an article written that stated consistent 'straight' dosing keeps patients more stable. i.e, 6mg or whatever x 7 days instead of 2 here and 3 there. It's no wonder some of us have ridden the roller costar! I asked my doctor to try the consistent dose with me after reading the article, poof! From that day forward I have been stable.

Everyone reacts differently to this medication. Once you have it figured out you are pretty much home free. And like anything, you become accustomed to that way of life. Coumadin is not a big deal to me. It's keeps me alive. I feel good. And happy with my decision to go with the mechanical valve for durability and longevity.

Hope that helps...
Good luck and keep us posted.
 
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I have no doubt that the same dose every day is best . The main reason that I do not use the same dose every day method is the patients that I treat. They are some of the lowest income people in the state. I've had them tell me that to get another prescription for a new strength would have to wait until next month. They spend their entire Soc Sec, Welfare etc check the day they get and have literally less than a dollar a day left for the rest of the month. So I have to work with what they have.
 
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