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INR up and own

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Warrick

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Hi just a quick question, my INR yesterday went down to 1.8 ,(2-3 range for mech st Jude) told to go from 6 mg to 7 mg daily dose, took 8 mg as a booster dose last night, did a self test this morning on coaguchek and INR has gone to 2.2, do others have it change that quick in 24 hours?? Thanks
 

dick0236

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A .4 change is not unusual. I did a test about a year ago by taking a daily INR without any changes in dose to see how the INRs varied:
day 1 2.6
2 2.8 +.2
3 2.8 0
4 2.3 -.5
5 2.2 -.1
6 2.5 +.3
7 2.3 -.2
8 2.7 +.4
All of these readings where at a dose of 5mg daily.

I suspect diet caused some of the variation but they are often due to strip/meter tolerances and I don't pay a lot of attention to any single reading unless it is way out of range.......and then I retest to confirm a puzzling reading.
 

W. Carter

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If you were to test everyday you will drive yourself crazy. I have found even when it is most stable, it is never stable. :)
I get mine checked every 4 weeks at the V.A. lab. God only knows what it would read if I checked it every day. My weekly dosage is 45 mg. - 7.5 mg. four days a week and 5 mg. three days a week. My prescription is 2.5 mg. pills so there is no cutting in half etc.
Last 3 months readings.
Month 1 - 2.7
Month 2 - 3.0
Month 3 - 2.5
*My INR range is 2.5 - 3.5, so I stay in therapeutic range.
 

pellicle

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Hi

Warrick;n861389 said:
Hi just a quick question, my INR yesterday went down to 1.8 ,(2-3 range for mech st Jude) told to go from 6 mg to 7 mg daily dose, took 8 mg as a booster dose last night, did a self test this morning on coaguchek and INR has gone to 2.2, do others have it change that quick in 24 hours?? Thanks
INR can change in 24 hours. Be careful to not over steer it and end up all over the place. Make that one change and observe.

I find that testing every 3 days is sufficient in dealing with out of range situations. You do need to give it some time as not only is your body load of warfarin changing, so too is your metabolism.

Be carefulv to not provoke a see saw effect.

Keep good records in a spread sheet and check your two period average trend lines.

1.8 is not a worrying number so dont panic about being below 2 ... its likely your body will swing back.


For interest read this post here to see an example of daily samples, he also makes the point about large INR changes correcting by themselves.

http://www.valvereplacement.org/foru...3179-novembinr
 

Warrick

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Ok thanks, I went down to 1.5 a week ago and had my dose increased from 4mg to 6mg and it was coming up at 2.1 but then I had another test yesterday and it had bombed down to 1.8, I think antacids bombed it to 1.5 as I find the aspirin hard on the stomach, I use the coaguchek when it plays up like this and I get pretty over testy, I've only been on warfarin for 8 weeks and my INR has already been from 1.5 to 7.7 so I guess I've got the rest of my life to get it right :)
 

pellicle

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Warwick

7.7 is worrysome. I suspect reading your post you are all over the inr shop because your doses are uneven. I am not sure why you are taking aspirin (or how much) as well , but it does not influence INR.

I strongly suggest you attempt an even unchanging dose, and try to fine tune that. If this requires you to have on hand some tablets of varying strength i urge you to do so.

Myself Ihave 5, 3 and 1mg on hand. My dose may be 8 mg daily or 7 mg daily it has varied over time.

I make 7.5mg by splitting a 5mg in two and adding that to another 5mg.
7mg by splitting a 3 and a 1 and adding that to a 5...

Flush the idea of weekly dose down the toilet where it belongs and shoot for consistent daily doses ... unless you like the roller coaster INR ride. But it will hurt you.

Keep the doses steady, make changes only when you clearly see a trend.

Warrick;n861399 said:
Ok thanks, I went down to 1.5 a week ago and had my dose increased from 4mg to 6mg and it was coming up at 2.1
2.1 is a good number, what target INR are you aiming at and what range are you looking to be between?

Try reading this, its a good reference and needs a few reads over time as you practice the parts.

http://cjeastwd.blogspot.com/2015/10...r-example.html

This is also a good follow up.

http://cjeastwd.blogspot.com/2014/05...ocks-dose.html
 

Warrick

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Hi Pellicle,
yes I got to 7.7 because I was on Miconazole, that was back 18/11/15, between my surgery on the 4/11 and then I was stable at around 2.4 (my target is 2-3 with mech St Jude) , then had 10 days of getting it right again, it settled back on between 2-2.6 on 4 mg for 16 days, then I had the low INR test on the 18/11 at 1.6, increased to 5mg retested on the 21/12 and was 1.5, dose increased to 6 mg, INR came up to 2.3 on the 27/12 but then retest on the 31/12 was down to 1.8 so doctor increased to 7mg.

I'm also on 100mg of aspirin daily that was what the surgeon wanted, although I've read and been told its not ideal it's common to be on with mechanical valve.
I was pretty worried when it went down to 1.5 ,when do you worry about clots ??
Should you have clexane(heparin) to cover until it comes up, the GP was almost going to give it to me, I'm 39 yrs old .Thanks
 

pellicle

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Hi

well its early days since surgery, so don't worry much. I believe that it takes about 6 months for your body to settle down after sugery ... so read that as meaning you may be making fine tuning adjustments till at least then.

Warrick;n861409 said:
... between my surgery on the 4/11 and then I was stable at around 2.4 (my target is 2-3 with mech St Jude) , then had 10 days of getting it right again, it settled back on between 2-2.6 on 4 mg for 16 days, then I had the low INR test on the 18/11 at 1.6, increased to 5mg retested on the 21/12 and was 1.5, dose increased to 6 mg, INR came up to 2.3 on the 27/12 but then retest on the 31/12 was down to 1.8 so doctor increased to 7mg.
I left the hospital on 4mg and it gradually wound its way up to 6mg in the first few months. I was a bit depressed about that back then as there was no one to speak with and I didn't know much (and the internet was hopeless at good information).

after that I took a full blown research methodology to it (as I had done in my Masters) and started reading only academic material and other rigourus materials. I soon learned enough to be considered sort of current in the field of AC dosing.

I'm also on 100mg of aspirin daily that was what the surgeon wanted, although I've read and been told its not ideal it's common to be on with mechanical valve.
yeah, I was on 75mg and I gave it up after about a year ... didn't see the benefit nor did I read anything that was clearly a benefit. If its causing you stomach grief then I would suggest that you discuss this with your doctor to see if you can drop it too.

I was pretty worried when it went down to 1.5 ,when do you worry about clots ??
there's no magic number, but its always about duration. Clots do not instantly form and generally its considered that with an aortic valve when having surgical procedures that AC can be discontinued for a few days without concern.

Should you have clexane(heparin) to cover until it comes up, the GP was almost going to give it to me, I'm 39 yrs old .Thanks
myself I wouldn't worry, but my advice is when its down to 1.5 test again in a few days and see if its trending back up ... if its not then take an extra 30% of your dose ONCE and then see where that goes in a week.

Myself I test every Saturday and examine my patterns. I keep the info in a spread sheet which has a graph of the INR and the dose (simple stuff) ... I find that a trendline helps, I use a 3period average to see if I'm trending down or just wacking around the extreems.

I don't know what your 'numeracy' literacy is like (I'm occasionally jaw dropped by people) but have a look at this graph and see how I've done things:



the 3 period moving average is helpful to show my INR's general trends and helps clear up the noise in the system. You don't need to worry about the Poly *but its interesting) and you can see that the worst area was where I decided to experiment with attempting to steer things. Clearly that resulted in the most variation. I did that because I wanted to test my view that it wasn't a good idea. I'd had a year or so of self managing and considered that if it was possible then I'd be able to do it. Well I confirmed to myself that I was right ... don't try to micro manage it.

Note also the dose increment is not big, its only between 8.5 and 7mg as a daily dose ... the graph scale makes the changes look big (deliberately)

When I see a clearly evolving trend I examine again in 3 days to see if its resolving by itself ... mostly it does with no intervention. Now my interventions are single adjustments (no more than 30% of a dose) to "whack it back" (up or down as needed) and resume the normal dose for the remainder of the week

Best Wishes
 

Warrick

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"I'm also on 100mg of aspirin daily that was what the surgeon wanted, although I've read and been told its not ideal it's common to be on with mechanical valve. yeah, I was on 75mg and I gave it up after about a year ...
didn't see the benefit nor did I read anything that was clearly a benefit. If its causing you stomach grief then I would suggest that you discuss this with your doctor to see if you can drop it too."

I thought the antiplatelet affect helped reduced the chance of clots as well at low INRs, the GP gave me Ranitidine 150mg for my stomach but told me not to start taking until my INR levels out.. I guess so it can muck it all up again :)
 

pellicle

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Warrick;n861415 said:
I thought the antiplatelet affect helped reduced the chance of clots as well at low INRs, :)
could well do ... but if it exacerbates bleeds in the gut its not a good trade off IMO

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1492499/
In the end, we are left with a striking lack of evidence regarding aspirin use in the most common warfarin indications. Unfortunately, the variations in outcomes among the conditions we were able to evaluate suggest that extrapolating from one warfarin indication to another may not be appropriate. Nonetheless, with over 2 million people in the United States affected by atrial fibrillation and approaching 200,000 new cases per year,40 the issues raised here will only become more relevant. For now, decisions about the use of aspirin in most patients receiving warfarin will need to be individualized in the absence of adequate data.

https://www.mja.com.au/journal/2000/172/12/consensus-guidelines-warfarin-therapy
The addition of aspirin (100 mg/day) further decreases the risk of embolism but increases the risk of gastrointestinal bleeding.
 

Warrick

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Ok thanks, my Dads got a 31 year old valve and he reckoned the aspirin was mucking my INR up ... but then he still thinks warfarin "thins "his blood , I see the cardiologist next Wednesday so I'll see what he says, he's pretty vague on information because I think he doesn't want to worry me... and I've got a few questions now as I was meant to have my ascending aorta replaced as a precautionary as its 41.6mm but the surgeon didn't deem it necessary which now that I've read a bit more is a lottery on future problems.
 

WillyWarfarinWizard

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I'm 57 years old and had my 2nd aortic valve replacement done last August. I chose to go with a mechanical valve this time instead of a tissue valve. My 1st valve was a porcine valve implanted in August 2002. I'm currently managing my INR in the 2.5 - 3.5 range as required. I manage this with 7.5 - 8.0 mg Warfarin each day. I get my INR measured at the lab on Mondays and home test with a Coaguchek XS meter on Friday. My physician mentioned to me my INR seems to be more prone to change than most of his patients. He also mentioned my dose is slightly higher than most patients who typically take 5 -6 mg/day. I'm very active and can say I'm the same weight when I was 16 and I like to eat different foods. I limit my alcohol consumption to 2 drinks/day with one day/week off. I once had a "culinary misadventure" where I consumed approximately 5 - 6 glasses of wine followed up with a glass of cask strength single malt. My INR shot up to 4.7 from 2.7. I skipped a days dose and managed to lower my INR to 3.6 the next day and to 2.5 the following day. My target is 3.0 - 3.5 and manage that by taking 7.5 mg/day for 2 days and 8.0 mg. on the 3rd day. If my INR trends up, I will go 3 days at 7.5 mg before I take 8.0 mg. If my INR trends down, I will alternate between 7.5 & 8.0 mg until I reach my range.
 

pellicle

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Hi WillyWarfarinWizard

I'm on my 2nd valve replacement my first was a human one, this one is a mechanical. I manage my own INR too. I see many of your questions are actually really "classics" in warfarin management. I hope that my reply helps

WillyWarfarinWizard;n862296 said:
I'm currently managing my INR in the 2.5 - 3.5 range as required. I manage this with 7.5 - 8.0 mg Warfarin each day.
that's a slightly higher range than is usual for an Aortic valve, do you have some other conditions which make stroke more likely? If not I'd question why you're higher than both the USA and European Surgical Guidelines for post operative management (which is 2 ~ 3).


I get my INR measured at the lab on Mondays and home test with a Coaguchek XS meter on Friday.

this is also a bit unusual as you are essentially being measured twice per week. I can see little benefit for that, although I'm a strong supporter of weekly measurements and bi-weekly if you are monitoring something. If you're having them checked twice weekly for the purposes of seeing if readings are the same between your home test and the INR at the lab, then you will be better off doing them within hours not days.

My physician mentioned to me my INR seems to be more prone to change than most of his patients.
without knowing your doctor I'll say that most doctors have so little actual knowledge on INR management that its embarrassing. I would take that with a grain of salt.

Firstly how long since your surgery? For the first year on warfarin you can see all manner of variations as your body reacts to the surgery and healing post surgery. I wonder how many of his other patients that are on warfarin are elderly and taking warfarin for stroke history or thrombosis? I'd say the majority.


He also mentioned my dose is slightly higher than most patients who typically take 5 -6 mg/day.
Unimportant, its like saying most of his patients are older and you're younger ... so what? The thing is we all have different metabolisms, and the whole point of warfarin is to adjust coagulation levels for YOU. So if you're a size 9mg man then just wear a size 9 and be happy. The amount of warfarin we take has only one real outcome - proper coagulation. Any perceptions of taking less for any other reasons are unfounded.

I'm very active and can say I'm the same weight when I was 16 and I like to eat different foods.
I can't claim the same weight, but I'm quite active for a 50YO .. I see in your Bio about your outdoor work and when I'm back in Finland (I'm in Australia now) I XC Ski almost every day that I can (which is usually from late Dec through till April) and cycle through out the year. In Finland I don't own a car and walk / cycle around town.

Eating food has far less impact than the internet will have you believe. If you search here you'll find many of us see little variation in INR that can be correlated with food. Although lay off the Grapefruit juice!

I limit my alcohol consumption to 2 drinks/day with one day/week off. I once had a "culinary misadventure" where I consumed approximately 5 - 6 glasses of wine followed up with a glass of cask strength single malt. My INR shot up to 4.7 from 2.7
Its hard to be sure that the drinking was the cause. I mean in science its well established to have a control (where no alcohol is taken) and at the same time an experimental (where alcohol is taken). Given that your INR can fluctuate its hard to be sure that THAT was the cause.

also, of and in itself 4.7 is just outside the safe zone, so don't panic there.


I skipped a days dose and managed to lower my INR to 3.6 the next day and to 2.5 the following day.
the important thing to remember with INR and warfarin is that its like a bucket with a hole in it: if you pour water in faster than the hole drains it, then water accumulates in the bucket. Slower and the bucket empties.

The hole for warfarin is your P450 pathway (liver related disposal) and so it can't pull out warfarin instantly. So the disposal rate is measured in half life. So half of what you took is disposed of in 48 hours. Because you'll also be taking more within 24 hours your getting more to top that bucket up.

So the key is "how big is your warfarin disposal rate" because it isn't exactly 48 hours and varies from person to person.

This is why we measure INR, because we can see from our INR (the only thing we are interested in really) that once the levels settle we know what we need to be adding to the bucket to keep an even level.

I say this because your monitoring and redosing strategy is going to result in over corrections (like a kid doing a tail slide on an ice track) ... you want to balance that slide. Over correcting won't help. There is an "old adage" that warfarin takes a week to react. The detail of the adage is wrong, but the message is correct. Leave it a week to be sure what its settling to.

I use a spread sheet and a graph to assist me. If you'd like to discuss that please use the message system here and get in touch.


My target is 3.0 - 3.5 and manage that by taking 7.5 mg/day for 2 days and 8.0 mg. on the 3rd day. If my INR trends up, I will go 3 days at 7.5 mg before I take 8.0 mg. If my INR trends down, I will alternate between 7.5 & 8.0 mg until I reach my range.
,

I think you're on a good method there, I feel that its important to keep the dose variations small such as you are. Myself I now make weekly changes of about 0.5 or 0.25mg if needed ...

I've got a few other points of interest to discuss if you're interested. I also use skype, so if you want we can chat about things (often easier than typing)

Best Wishes
 
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