INR - constant changes

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Poyda

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Oct 27, 2018
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25
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Adelaide, Australia
Hi all!


Have a question is it normal for INR to suddenly change dramatically.


I had an MVR with a mechanical valve in March this year and since then getting me a constant dose of Warfarin had been a task. Dosed by GP. Target INR 2.5 - 3.5


For a good period of time after surgery (maybe a month or two) I was 8, then over time then, as it would drop, I've slowly had to get the point where I take 13mg. Anyone else on a similar dose?! 13mg is massive to me.

My INR had been (fairly) stable the past month and a it generally fluctuating between 2.6 - 3.0. Last week it was 2.8 and Yesterday I had an INR and it's at 3.7 why would this be? No new meds, no new medication basically the same routine.


Has anyone else had issue getting thier INR stable

My GP isn't in today I don't know what I should do with tonight's dose




MVR 3/2/18 due to Infective Endocarditis. St Judes Mechanical Valve.
 

dick0236

Eat the elephant one bite at a time
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louisville, KY USA
Poyda;n885592 said:
Hi all!


Have a question is it normal for INR to suddenly change dramatically.


I had an MVR with a mechanical valve in March this year and since then getting me a constant dose of Warfarin had been a task. Dosed by GP. Target INR 2.5 - 3.5


For a good period of time after surgery (maybe a month or two) I was 8, then over time then, as it would drop, I've slowly had to get the point where I take 13mg. Anyone else on a similar dose?! 13mg is massive to me.

My INR had been (fairly) stable the past month and a it generally fluctuating between 2.6 - 3.0. Last week it was 2.8 and Yesterday I had an INR and it's at 3.7 why would this be? No new meds, no new medication basically the same routine.


Has anyone else had issue getting thier INR stable

My GP isn't in today I don't know what I should do with tonight's dose
Most people on warfarin will tell you that there is often no rhyme or reason for INRs to bounce around the way they do......that's why they give us a one point spread in our dosing range.....2-3 or 2.5-3.5....and everything is OK so long as we stay anywhere in or close to that range. I would make no change if I got a 3.7......my range is also 2.5-3.5. Your next test will likely be in range.....but if it is still above your upper limit a little, hold a dose.

13mg is not all that unusual......it takes what it takes. When I was young I took 10mg/day but that has decreased over time as I have gotten older and sedentary. Today, at 82, I only take half that much.....5mg/day to maintain the same INR.
 

Ryanvs

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Jan 10, 2016
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113
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Newcastle, New South Wales, Australia
Hello. My target range is 2-3 and my daily dosage is 6.5mg. My Average INR for this year is 2.6.

I record and track my INR weekly and leave notes with any High (above 3.0) and Low (below 2.0) readings.

The lowest my INR has gone this year was 1.9 and my notes were; "Previous weeks were 2.1/2.2/2.2. Retesting Tuesday. Tuesday Test 2.2. No change to dosage"
The Highest my INR has gone was 5.5. This was due to a bout of really severe gastro. I managed it, mid-week it was 3.9 and by the following Saturday it was 2.5.

By doing this, it has helped put my mind at ease when I have an 'abnormal' reading, and allows me to refer to previous tests and see what actions I took then.

My INR does jump for no reason but things I have noticed that do effect it are:

* Alcohol - If I, say, have 3 beers on Saturday, then for the most part there is no change in my next INR reading (nothing abnormal or really noticeable anyway). However, if I go on a family holiday and have 2-4 beers per night for a week, my next reading will be higher.

* Paracetamol - If I have a cold for example and take paracetamol for an extended period of time (Maybe a 4 days to a week) I will generally see an increase in my INR around a week later.

* Gastro - As above. I believe the reason is due to your body not absorbing vitamin K. So that combined with warfarin can have a more profound effect ***** This is my understand. Please feel free to correct me****

Laxatives - I have used these twice. A few months ago and recently I was in hospital for my paravalvular leak closure and when I came out as I was on pain meds they also gave me laxatives to stop me from getting constipated. Both occasions my INR went up.

This is just my experience, but your INR will jump. Recording it will help you undertsand it a little bit better and also help put your mind at ease.

I hope this helps
 

Warrick

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New Zealand
I went from 5mg daily up to 9mg over a few months after surgery also and from what I’ve read from numerous posts and sources is its completely normal and even expected.
13mg is just the amount you need to be in range, the intended target is the INR range not the dose needed to be there, I think if you read some of the older posts here I seem to recall someone on 45mg to be in range.
Jumps in INR can be expected and just dont panic, a change for me can be from 2.6 one week to 3.5 the next which I make a slight dose change to over a few days and then I go back to my usual dose.
Over time you will learn what works best for you.

I also had issues early on with no GP contacting me and wondering what do I do now?
Thats where self testing and self management shines as the way to go IMO
 

pellicle

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Hi

Poyda;n885592 said:
Have a question is it normal for INR to suddenly change dramatically.
no, its not, but reading through your post your INR hasn't changed dramatically.




I had an MVR with a mechanical valve in March this year and since then getting me a constant dose of Warfarin had been a task. Dosed by GP. Target INR 2.5 - 3.5
yep ... all good ... but as an observation its pretty normal for your dose to go up after surgery, usually its after 3 to 6 months.


For a good period of time after surgery (maybe a month or two) I was 8, then over time then, as it would drop, I've slowly had to get the point where I take 13mg. Anyone else on a similar dose?! 13mg is massive to me.
nope ... not even close to massive. Like Dick says, it takes what it takes ... I've read of doses well over 50mg daily.



My INR had been (fairly) stable the past month and a it generally fluctuating between 2.6 - 3.0. Last week it was 2.8 and Yesterday I had an INR and it's at 3.7 why would this be? No new meds, no new medication basically the same routine.
well up to 3.7 is really just out of range and its still well within a safe range (reference again "that table"



so looking at that graph you need to be seeing an INR over 5 to be in any statistical risk of an event (usually a bleed). However unless you fall down the steps and bonk your head an INR of 5 does not mean spontanous bleeding to death.


Has anyone else had issue getting thier INR stable
if I left my dosing to a GP or a clinic my INR would be all over the shop (and it was), so I took control of the issue and managed my INR myself. I tweak my dose frequently in response to what I observe in weekly readings (with my Coaghcheck).

which leads me to ask ... how did they determine your INR?
 

Poyda

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Adelaide, Australia
pellicle;n885600 said:
vein draw or finger stick?
Vein Draw! Seeing as you're an Aussie, I get it done through clinical labs if you've heard then.

I've found that more "accurate". post - surgery (hospital iin the home) were doing both and sometimes there'd be a discrepancy of a few points from finger to vein i.e Finger - 2.6 and Vein 2.9 (from memory)

I dunno if this normal or not but regardless my GP doesn't even the finger machine and getting one for myself, would proabably cost a fortune.

So vein it is. Getting it done every week is taking it toll on my veins
 

Poyda

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dick0236;n885593 said:
Most people on warfarin will tell you that there is often no rhyme or reason for INRs to bounce around the way they do......that's why they give us a one point spread in our dosing range.....2-3 or 2.5-3.5....and everything is OK so long as we stay anywhere in or close to that range. I would make no change if I got a 3.7......my range is also 2.5-3.5. Your next test will likely be in range.....but if it is still above your upper limit a little, hold a dose.

13mg is not all that unusual......it takes what it takes. When I was young I took 10mg/day but that has decreased over time as I have gotten older and sedentary. Today, at 82, I only take half that much.....5mg/day to maintain the same INR.
Cheers for the reply mate! Massively helpful!

Also how did you get the blue text bit down the bottom of your post?
 

pellicle

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Hi

Poyda;n885601 said:
Vein Draw!
Ok, so that rules.out what I was going to ask next.

I'm a long term self tester and do 6 month to yearly comparison, the difference is not clinically significant (like the difference you mention).
​​​​​

So vein it is. Getting it done every week is taking it toll on my veins
Longer term you'll want to consider finger stick because it will ruin your veins.
 

Superman

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Grand Rapids, MI, USA
Going on 28 years on Warfarin. Early on, 4 - 5 mg daily would keep me in range. Now I’m 6 - 7.5. I’ll have weeks where is raises or dips for now clear reason. I operate under the assumption that there is a reason, just not a clear one. Diet, exercise (or lack thereof), weight fluctuations, sleep habits all seem to have some kind of impact. That’s why I test weekly and adjust dosing as needed.

I get the impression that some newer Warfarin users are hoping for a particular dose that once they find it, they will never have to change again. That’s the dose that works for them. That has not been my experience. I think if it were the case, we wouldn’t need anti-coagulation clinics to manage this medication. Many home testers still partner with a clinic for tracking and dosing.
 

Poyda

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Adelaide, Australia
pellicle;n885603 said:
Longer term you'll want to consider finger stick because it will ruin your veins.
How easy is it to get one? Also seeing that you're down under as well, is there anyway a can get one discounted by Medicare or something? I don't have large amounts of cash to get one and I know the there pretty pricey
 

pellicle

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Hi
Poyda;n885611 said:
How easy is it to get one? Also seeing that you're down under as well, is there anyway a can get one discounted by Medicare or something? I don't have large amounts of cash to get one and I know the there pretty pricey
I was fortunate enough that ATS (my valve maker) gave me one. But having used it now for some years (like since 2012) I can say that its been critical to
  • good outcomes,
  • me learning about my own INR
  • saving money (yes saving money)
To my knowledge there is no support from Medicare for one nor from my BUPA insurance, however it works out at about $6 per test and I have not needed to be constrained by labs (so I can travel as I wish, visit and stay with friends, essentially be free). Imagine trying to sell a diabetic on going back to lab draws to manage their sugar levels?

There was a time one would see them on eBay, but people seemed to have wised up to the usefulness of them. I find (in a quick search) that right now in Australia the cheapest price seems to be on the web-shop that I use to buy my strips:

https://www.medshop.com.au/products/coaguchek-xs-au-meter

Before you buy one there are some rare and unusual blood disorders which can make them unreliable for those people. A bloke over in NZ Warrick knows these well, but as I don't have such a problem I tend to forget what they are.

I'll do a little search and see if I can hit on them
 

pellicle

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hey Poyda

Antiphospholipid Antibody Syndrome (APL) is an autoimmune disease that increases ones risk for blood clots. Therefore, these patients receive anticoagulation therapy with warfarin. Point of care devices such as the CoaguChek XS are often used to monitor International Normalized Ratio (INR) in patients on warfarin. However, the antibodies present in patients with APL may lead to false INR results when using the CoaguChek XS. This study will compare the accuracy of the CoaguChek XS in measuring INR in patients with APL by measuring INR by the CoaguChek XS and a standard lab as a reference point. Patients on warfarin for indications other than APL will be measured by both methods as well to serve as a control group.

(btw, is that Finnish for table (although that would be with a T not a D, but it would sound like it was a D)
 

LondonAndy

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London, UK
I agree with other comments - your fluctuation is not huge, and dose not out of line, as there is no "line" - just what is required to achieve the correct result.

For me, I saw a change in dose steadily after surgery, which then has generally stabilised. Diet changes and how much alcohol I drink (though I am an occasional and moderate drinker) are minor effects; for me colds and flu are much more dramatic, along with taking antibiotics.

I am a huge fan of self managing my dose with my handheld meter. Here in the UK I had to buy my meter (£300 / US$ 390 / AUD 540) and then I get my test strips free of charge, but they would be £4 / $5 / AUD 6 each if I had to pay. But it gives freedom from labs, ability to test more frequently (weekly instead of 4 to 8 weeks in clinics here - way to big a gap if something knocks my INR off course), and easier on the veins.
 

Warrick

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Messages
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New Zealand
To add to pellicle post-
antithrombin III deficiency, Factor V Leiden, protein C deficiency, and protein S deficiency are the other blood clotting disorders that may require anticoagulation

As far as I’m aware APS is the only one that coagucheks have been deemed inaccurate for INR monitoring.
prothrombin time home testing units are still considered “experimental” by some insurrance companies and investigational for all other indications (e.g., arterial embolism to the eye, atrial flutter, and Kawasaki disease) because its effectiveness for indications other than the ones listed above has not been established.
 
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