INR level way above recommended range, it's 1AM, what should I do?

[Warfarinking]

Hi all, I have an aortic valve and my range is 2.5 - 3.5. I've been consistent for most of the years but today I got a test result back at 1AM indicating my INR was 4.7. Not sure what to do, I'm pretty paranoid about it. Looking for advice. Thanks

 

[pellicle]

don't sweat it ... 4.7 is not dangerous.

I'd halve my next dose and resume as normal let it come down slowly. Test again in 3 or so days ...

This chart shows INR levels across a research group of thousands and their reported amounts of issues. You'll see that at 4.7 it was still very low incidence of problems

[IMG2=JSON]{"data-align":"none","data-size":"full","src":"https:\/\/c2.staticflickr.com\/4\/3868\/14626794599_c646b1872d_b.jpg"}[/IMG2]

You'll be right

 

[dick0236]

I agree with Pellicle.

 

[Warfarinking]

Hi,

Thank you for your replies! I did my INR testing at the lab Friday in the morning but didnt get my test result until 1 AM Saturday so I took my medication that Friday as normal again (which wont reflect on my INR test so it will be higher than 4.7 probably). I'm going to take your advice, instead of 9MG take only 3MG and have a salad on the side to hopefully bring it down. Thanks!

 

[pellicle]

...instead of 9MG take only 3MG and have a salad on the side to hopefully bring it down. Thanks!

welcome ... but I'd then resume your regular 9 after that (or perhaps 8 for a couple of days).

Normally such things are marked by something like a drug ... did you take anything? Drink heaps of grapefruit juice? Use any "rubs" like voltaren?

 

[ashadds]

don't sweat it ... 4.7 is not dangerous.

I'd halve my next dose and resume as normal let it come down slowly. Test again in 3 or so days ...

This chart shows INR levels across a research group of thousands and their reported amounts of issues. You'll see that at 4.7 it was still very low incidence of problems

[IMG2=JSON]{"data-align":"none","data-size":"full","src":"https:\/\/c2.staticflickr.com\/4\/3868\/14626794599_c646b1872d_b.jpg"}[/IMG2]

You'll be right

Hi Pellicle is this chart accurate with the on-x valve ? In their website they claim a target INR of 2 - 3 with successful management with INR 1.5-2

 

[pellicle]

Hi

Hi Pellicle is this chart accurate with the on-x valve ? In their website they claim a target INR of 2 - 3 with successful management with INR 1.5-2

that isn't how research works. This represents the results of what was found with a group of people in a research study. Its not like a compatible part look up for a vehicle. It represents what they found. Which if you look shows a very low level of incidents (bleeding or clot) between obvious ranges.

How does this relate to the On-X? Well the On-X has had what I consider a limited trial at lower INR I'd guess that the results of On-X would be better at the lower end of the INR range than the results here. At INR ranges above 2.5 (which was what the OP was worried about) then I'd say that valve type (meaning On-X) is no longer a factor and thus those data should hold for you. The On-X claims revolve around how their design can tolerate a lower INR than the current recommendations.

Other research I've point out here suggested that other valves such as ATS, St Jude and Carbomedics can indeed tolerate INR a little below 2 without difficulty, but they have not gone to the trouble of getting approval for that.

As I've said before there is no reason to attempt to target a lower INR than 2.5 (note: this is the INR target, not a range, a range would be 2.0 to 3.0 ... but targets are achieved differently) because it only increases the risks that any small variation in your INR will drop you below 1.5 (were you targeting 1.7 for instance) and possibly bring you to harm. There is no benefit to the minor reductions in warfarin dose and indeed there has never been a study that I have ever seen suggesting that lowering warfarin dose provided ANY benefit of ANY nature.

Let me know if you want the full paper that the above graph comes from and I'll dig it out

you need to be very careful how you interpret the On-X claims ... I'm not disagreeing with them, but if you don't understand the numbers you're reading then you may get a surprise.

 

[pellicle]

PS

read the On-X claim carefully:

The On-X aortic heart valve is the only mechanical valve FDA approved and clinically proven to be safer with less anticoagulation. In a prospective randomized clinical trial, On-X aortic heart valve patients with a reduced warfarin dose (INR 1.5–2.0) had 65% fewer harmful bleeding events without an increase in stroke risk.

so their range is 1.5 to 2.0 - they do not say what happend if you drop out to 1.4 or how indeed you would accurately determine that (as no two measurement methods are going to obtain the same numbers.

I believe what this should be taken to mean is "don't panic if you go lower than 2" ... NOT to be meaning try to sit on 1.5

I believe you will read here of a number of patients who have had their surgeons and cardiologists say "well On-X can claim what they like but I want you on 2.0 - 3.0 please"

Lets look carefully at the On-X study:

https://www.ncbi.nlm.nih.gov/pubmed/24512654

The INR was adjusted by home monitoring; all patients received 81 mg aspirin daily. Adverse events were independently adjudicated.

RESULTS:
A total of 375 aortic valve replacement patients were randomized into control (n = 190)
and test (n = 185) groups from September 2006 to December 2009.

The mean age ± standard deviation was 55.2 ± 12.5 years;
79% were men; and 93% were in sinus rhythm preoperatively.

... The follow-up duration averaged 3.82 years
(755.7 patient-years [pt-yrs] for control; 675.2 pt-yrs for test).

The mean INR was 2.50 ± 0.63 for the control and 1.89 ± 0.49 for the test groups (P < .0001).

The test group experienced significantly lower major (1.48% vs 3.26%/pt-yr; P = .047) and minor (1.32% vs 3.41%/pt-yr; P = .021) bleeding rates.

The incidence of stroke, transient ischemic attack, total neurologic events, and all-cause mortality were similar between the 2 groups.


CONCLUSIONS:
INR can be safely maintained between 1.5 and 2.0 after aortic valve replacement with this approved bileaflet mechanical prosthesis. With low-dose aspirin, this resulted in a significantly lower risk of bleeding, without a significant increase in thromboembolism.

They do not say "sit on 1.5" that's an outter limit ... their target was 1.89 Can you achieve no more variance than 0.49 INR units?

Are you taking the 81mg of Aspirin?

Myself, I go with the evidence

 

[Warfarinking]

Update: on Saturday I ended up taking 3MG instead of 6 mg. Sunday I took my dose as normal (9MG) and Monday my INR doctor called me to tell me to take only 6MG that day instead of 9MG. Tuesday I took it my medication as normal. Today (Wed) I went to get my INR checked, haven't had results yet.

 

[Warfarinking]

Update: on Saturday I ended up taking 3MG instead of 6 mg. Sunday I took my dose as normal (9MG) and Monday my INR doctor called me to tell me to take only 6MG that day instead of 9MG. Tuesday I took it my medication as normal. Today (Wed) I went to get my INR checked, haven't had results yet.

 

[pellicle]

Update:. Today (Wed) I went to get my INR checked, haven't had results yet.

Fingers crossed that it's all good

 

[Warfarinking]

test result from yesterday came in today, I'm at 2.7 and within my range thanks for the help!