Low INR

[Lorraine]

Hi Everyone,

I'm almost six months postop. I went to for my INR yesterday and my reading was a 2.0. The previous readings were always at the 2.5-2.7 level. I didn't change how I was eating, don't do green leafy vegetables except occasionally and this past weekend I hadn't even done that. I looked up research on low INR's but couldn't find out why it would go down. The only information I could find was on a high INR. As a result my doctor has told me to take 10 mg a day for three days, of Coumadin. Then go back to my normal dose. I had steadily been on 7.5 the whole time I've been on Coumadin. The office wants to see me in two weeks to check the level. I just want to find out if anyone knows why it would go down other than Vitamin K (which I don't believe i had any). All answers appreciated.

 

[Perrster]

Pesky INR's

Pesky INR's

Lorraine,

You must have done SOMETHING different? You'll have to think very hard about what you've eaten or changed in your diet, vitamins, supplements, etc.

My INR went to the basement a few months ago and we figured it out that it was caused by a new brand of vitamins I started taking (darn things had 60mcg of Vit K in them and I bought them from my doctor!). Oh well, I stopped taking them and went to an over the counter mixture of vitamins and the next INR was back in safe range. I had also started a Red Yeast Rice supplement as well as a daily soy protein powder supplement, so my diet was a dicombobolated mess for a bit.

Think hard!

Good luck.

PerryA

p.s. I re-test this Friday to see if everything has settled down. I hoping to get back to a once-a-month PT test. I hate vampire bats!

 

[Christina]

Hi Lorraine,

You just never know with INR (stands for: "It's Never Right") and I have been many times like you that it is low, and I don't know why. Doing the same thing, although I eat whatever I want in moderation. I am NOT avoiding green leafy vegetables because I am on Coumadin, but if I don't feel like chewing another salad I don't. I also like hot mixed vegies, broccoli, cauliflower etc.etc..
INR interferes with many things, diet, weather, kids, husbands, OTC meds, (LOL) and you just have to do the best you can. Check all OTC meds with your doctor.
I pretty much had it with doctors though, because the one before the new one I have now had me on such crazy dosages, and my INR was all over the place. But I finally found a nice doctor who lets me home test, and since I've been doing that I've been fine. I call it in to his office once a week, and he's fine with that.

Hope this helps.

Christina
Aortic Stenosis
AVR 8/7/00 & 8/18/00
St.Jude's mechanical
Coumadin 19mg a day.

 

[Guest]

There was an article published in the American Journal of Cardiology in 1999 about a study which showed that as people improved after valve surgery, that they needed larger doses of warfarin. This happens to almost everyone who improves from a fairly serious illness. My letter to this effect was published a s a follow up to this article in 2000.
My theory is that when you are shortly post-op, you do not feel well. Therefore, you are not very active and do not eat well. Therefore, you do not metabolize warfarin well and need a small dose. As you improve, your heart beats more efficiently. Warfarin is only metabolized when the blood carrying it passes through your liver. More efficient metabolism means a larger warfarin dose is needed. Also as you feel better, you resume your normal food intake. This increases your vitamin K intake, resulting in the need for more warfarin.
I warn my patients ahead of time that as they improve, they are going to require larger warfarin doses, so that thye are looking out for this to happen.
The reverse is also true. If someone breaks an ankle or something that slows their activity, they will need their warfarin dose lowered.

 

[Lisa in Katy]

So many things affect the INR - diet, heat, activity level, other meds, etc. I also think that hormone levels may affect it, and in ovulating females these vary, so it's probably better to try to stick to the same time in your cycle. Seems like I haven't been able to go a month between tests in a while, but when I get back on that schedule, I think I might get better results.

 

[LUVMyBirman]

Hi Al

Have found your theory to be right on! Post surgery they had me on 6mg. It was obviously too much because within two days my INR spiked causing tamponade. It's funny......as my activity increased I ended up on 6mg and remained there for two years until recently. Major activity increase has bumped me up to 7mg. I also eat a very low vitamin K diet.

Guess I just process fast or better yet my heart function is exceptional.

 

[Guest]

There is another part to it, also. People who take high doses of warfarin do so because they metabolize it faster than normal. So, if a person taking 7.5 mg daily has a high INR and you need to hold warfarin, their INR will drop to about 1/2 of what it was previously in one day. But a person taking 2 mg of warfarin daily may require three days for the same INR to drop to 1/2 its previous level.
The usual half-life is about 2 days but it varies wiidely depending on the dose the person requires. I take the dose into account when I am advising someone on how long to hold warfarin to get an INR back down to a prescribed level.

 

[LUVMyBirman]

Hi Al
Once again.....you have it all figured out! Your a breath of fresh air. Wish there were more professionals like you available.

My former hematologist's office refused to treat each patient on an individualized basis. The Coumadin nurse was taking general orders from the MD and applying them to all of the patients. I was informed of this method when things were not working and my levels were all over the place.

Halving my dose when it is out of range (too high) defiantly, like you stated puts me back where I belong.

PS. Any thoughts on monthly hormonal changes and the INR ???
I am starting to track this as it seems to be of concern in my case.

 

[LUVMyBirman]

Hey Janie

What do you know.....I am 5.6 today. Working on getting it down!My increased activity lowered me...upped myself the 10% and now it's too much. Can't win with this stuff. Off to have myself a salad and back to my regular dosing schedule.

In a nutshell....look at those of us that 'fast metabolize' seems we have the most turbulent swings in our INR's!

 

[Guest]

What a weekend. Instead of just my wife and I we had 6 people Saturday, it grew to 8 yesterday and 11 today. It is the first time that my son and daughter have been here at the same time with their children. Then one of our former foster children found us and asked to get reconnected, so she brought her two children today. !!!
Gina's comment about her hematologist refusing to individiualize reminds me of why I do not want a computer program. Warfarin management is an art, not a science. Yesterday, was my 4th anniversary of dosing warfarin full time. My patients have become my friends, not just data points.
Janie's question about how long it takes to form a clot is unknown and will remain forever unknown. The only way to find out would be to take a big group of people with the same type of valves and randomize them to a treatment or a placebo group. Then watch the placebo group until they clotted off their valves and do the statistics.
The longest I've seen anyone go with St. Jude valves and no warfarin was about two weeks. This was a 59 year old lady who had a minor bleed into her brain. She recovered about 95% of her prior abilities. Mostly short-term memory loss.
Gina's question about hormonal cycles is a difficult one. The average age of my patients is 70 years, so I see little of that problem. I do see one possibility though. If you retain fluid in the cycle it could interfere with warfarin metabolism. The theory is that when you gain fluid weight, the water congests your liver. Warfarin is only metabolized when the blood carrying it passes through the liver. A congested liver means less metaboolism and an increased INR. When you lose this weight, the warfarin is metabolized more efficiently and the INR drops. Congestive heart failure is big here too.
I've noticed something else too. People who have INRs that go above 8 tend to be small people. I think that it is because when small people do not feel well, they tend to not eat and the INR goes up. Whereas, with a guy my size, he will say, "Oh I have a stomach ache, I'd better eat a tube of Ritz Crackers and see if I can calm it down." Let me know what you think about that theory.

 

[LUVMyBirman]

When my INR gets too high it rarely goes over 6.5. Usually my highest reading is in the mid 5's. I am a tall..... about 5 10' of medium frame. Consider myself average.

Al, your theory on the metabolism in the liver and water retention during a woman's monthly cycle makes perfect sense! The last two months I have spiked at that particular time. Makes having a Coaguchek well worth it.

Any chance you could make an appearance in Nashville to speak at our 'Union'? We would love to have you!

 

[Perrster]

We Want Al! We Want Al!

We Want Al! We Want Al!

I second Gina's request of allodwick's guest appearance at the Reunion! Please? Pretty, please?

 

[Guest]

There is a chance that I could come - maybe to have a session on Saturday.

Is there any possibility of helping with some of the expenses.

I would not charge any speakers fee.

 

[Hank]

Guest Speaker and Expenses

Guest Speaker and Expenses

While we would love to have you as a guest speaker at the reunion, there is at this time no fund set aside for such expenses. Those attending are doing so by paying for 100% of the costs out of their own pockets. Please do not take this as a denial of our desire to have you share with us your knowledge, but only as a statement that there is no money with which to pay your expenses.