May have forgotten warfarin for two days

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DachsieMom

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So it was 3.1. Maybe I didn’t forget, or only forgot one day and not two. I did take extra strength Tylenol on two days due to migraines, and I had a beer which I never do! Weird. I am back to using the pill box.
 

Protimenow

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A few things:
As Pellicle said, you should be okay even if you miss a day or two.

A study by Duke University Clinic (I'll have to look that up), determined that it takes about a week with a low INR for clots to form on valves, causing potential problems. A day or two with a slightly low INR shouldn't be a big problem.

(Over the years, after eating too many greens, my INR was low. I took 1/2 dose, then the regular dose, and over the next few days, INR was back in range. I also have Lovenox, but didn't see a need to use it.)

I take 81mg aspirin daily - at night. These things are less than a penny each at Costco, and are probably similarly inexpensive in most places where they sell the generic low dose aspirin.

Low dose aspirin is supposed to help reduce the risk of heart attack (probably by making platelets less sticky). I take it because it doesn't seem to do any harm, and the possible benefits outweigh the cost and the risks. (My 81 mg aspirin are enteric coated, so they don't dissolve in the stomach)

I use a pill box, too. In my case, I take all my meds before bedtime (maybe not the best idea), and know the next morning if I missed my meds the night before. The Warfarin and aspirin are in the same compartment each night.

Timing of warfarin isn't critical - it takes about three days for the effects to show up in the INR (I'm doubtful about INR changing from the dose taken showing up as a change in INR the next day) so separating Warfarin and aspirin by two hours probably has no effect on either medication.

If I have a question about my INR (perhaps it's too low or too high and I change dosing) I MAY test next day. I normally test weekly.

---

For a clinic to be happy with testing every three months, this shows that a) the clinic knows that you're self-testing and self-managing, or b) they don't have a clue about how warfarin works. A major change in INR could cause a stroke in a week or two, or perhaps a bleeding event - waiting THAT LONG between tests is crazy.

This is one of the reasons that I self-test - clinic protocols are often way out of date and in little contact with reality.

---

I used to get a blood draw monthly - insurance paid for it - but I've stopped taking that extra step. I don't know if insurance covers it, and I trust my meter so much that such a test is probably (in my case, it's more like 'definitely') unnecessary, except to confirm the accuracy of my meter.

---

Back to the original question - I agree with what Pellicle advised.
 

Protimenow

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One more thing:

The loss of vision and, in my case numbness in one arm and numbness in the tongue, was a reaction to Zyrtec. I know of two others who had the same reaction to it. The issue reported in an earlier post in this thread may have been entirely unrelated to Aspirin. If you're taking Zyrtec, you may want to avoid it, if you experience these scary (but relatively quickly resolving) issues.
 

vivekd

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@vivekd What do you call too low before you use the lovenox injections?
I've On-X valve in aortic position and On-X recommends 1.5 - 2.0 with 1 baby aspirin. However my current INR recommended range is 2.5 - 3.5 (because my INR fluctuates a lot)
If my INR ever goes below 2.0, i plan to do the following for at least 2 days and then retest.
  1. increase my warfarin dosage for 2 days.
  2. take full strength aspirin (325 mg) instead of baby aspirin (80 mg) for 2 days.
  3. lovenox injections for 2 days (every 10-12 hours). Lovenox strength is determined by the body weight.
  4. May be couple of beers (if INR is around 1.4-1.7)
  5. Retest after 2 days
  6. Reassess.
I'd a TIA in 2018 because of warfarin mismanagement where my INR was somewhere between 1.5 - 1.9 for a week.
Therefore me and my cardiologist have decided to be more aggressive with INR management.
 

Warrick

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Thanks @vivekd
I was Just curious as in the first few months of starting warfarin when I was in the progressively increasing dose phase I went as low as inr 1.5/1.6 a few times but never had lovenox
 

vivekd

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Thanks @vivekd
I was Just curious as in the first few months of starting warfarin when I was in the progressively increasing dose phase I went as low as inr 1.5/1.6 a few times but never had lovenox
usually you don't need lovenox, if you're not sub-therapeutic for few days, but since I'd a TIA in 2018 and my INR fluctuates a lot (I take 13 mg to maintain 2.5 - 3.5), I don't want to take any chances.
 

tom in MO

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I've On-X valve in aortic position and On-X recommends 1.5 - 2.0 with 1 baby aspirin. However my current INR recommended range is 2.5 - 3.5 (because my INR fluctuates a lot)
If my INR ever goes below 2.0, i plan to do the following for at least 2 days and then retest.
  1. increase my warfarin dosage for 2 days.
  2. take full strength aspirin (325 mg) instead of baby aspirin (80 mg) for 2 days.
  3. lovenox injections for 2 days (every 10-12 hours). Lovenox strength is determined by the body weight.
  4. May be couple of beers (if INR is around 1.4-1.7)
  5. Retest after 2 days
  6. Reassess.
I'd a TIA in 2018 because of warfarin mismanagement where my INR was somewhere between 1.5 - 1.9 for a week.
Therefore me and my cardiologist have decided to be more aggressive with INR management.
Why do you have a range of 2.5-3.5, do you have a co-morbidity beyond your artificial valve that requires such a higher range then recommended by the manufacturer?


It that regimen of aspirin, lovenox and beer prescribed by your cardiologist? To me it seems severe. My range is 2-2.5, what's recommended for my valve. I've been down as low as 1.5 for surgery w/o anything other than an increase in warfarin immediately after surgery for two days and testing in 5 days. Same when I went to 1.7 for "who knows why." The "increase warfarin and test more frequently" was what the cardiologist warfarin specialist prescribed.
 

vivekd

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Why do you have a range of 2.5-3.5, do you have a co-morbidity beyond your artificial valve that requires such a higher range then recommended by the manufacturer?


It that regimen of aspirin, lovenox and beer prescribed by your cardiologist? To me it seems severe. My range is 2-2.5, what's recommended for my valve. I've been down as low as 1.5 for surgery w/o anything other than an increase in warfarin immediately after surgery for two days and testing in 5 days. Same when I went to 1.7 for "who knows why." The "increase warfarin and test more frequently" was what the cardiologist warfarin specialist prescribed.
standard INR recommendation for aortic position is 2-3. However my INR fluctuates more than 1 point within 2-3 days and therefore we (me and my cardiologist) agree to 2.5-3.5. I try to be around 3.0, so that even if i my INR goes down by 1, I'm still a 2.0.

I'm moving to brand name coumadin next week to see if crazy fluctuations are because of generics or not. These are my last 6 INR readings with absolutely no change in diet, workout or warfarin.

June 12 4.2
June 8 3.4
June 5 3.9
June 2 2.9
May 29 3.2
May 22 3.8
 

Protimenow

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Your approach sounds pretty extreme.
Tylenol (acetaminophen) won't have an effect on your INR. I'm not sure about beer having any effect, either.

Increasing aspirin dose may make your platelets a bit less 'sticky' but their effect can't be determined by a blood test.

Clotting on a heart valve should take at least a few days to happen - or to develop to a size that's of concern. (I, too, had a TIA because I trusted my meter's 2.6, when I actually had an INR that the hospital said was 1.7, so I have a pretty good idea where your thoughts are).

I've used Lovenox at times when I had to bring my INR to 1.5 or lower for sinus surgery or other things, if my INR tests near 1.0, or for other reasons, and keep some doses on hand, but hate to use it.

A day or two below 2.0 doesn't really worry me (I have a St. Jude valve with 2.5-3.5 INR recommended).

It's interesting to read about your INR dropping so quickly. The only time my INR dropped so quickly was if I had a lot of greens that I don't normally eat, or if the 'extremely low dose' Vitamin K that I took WASN'T so low.
 

tom in MO

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standard INR recommendation for aortic position is 2-3. However my INR fluctuates more than 1 point within 2-3 days and therefore we (me and my cardiologist) agree to 2.5-3.5. I try to be around 3.0, so that even if i my INR goes down by 1, I'm still a 2.0.

I'm moving to brand name coumadin next week to see if crazy fluctuations are because of generics or not. These are my last 6 INR readings with absolutely no change in diet, workout or warfarin.

June 12 4.2
June 8 3.4
June 5 3.9
June 2 2.9
May 29 3.2
May 22 3.8
That makes you "special" :)

I read up on brand name vs. generic vs. same factory about 6 years ago. There didn't seem to be a compelling reason to go brand name or with one manufacturer. The times my INR has gone wacky it wasn't due to a change in manufacturer. But you are obviously special :)

I do know that most drugs (e.g. your BP medication) the active dose must be within 90 - 110% of label claim, but due to the activity of warfarin it's tighter and must be 95-105% of label (US Pharmacopoeia specifications). There is also a content uniformity requirement.
 

vivekd

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I have really high metabolism (never gain weight). I've gone on bulking phase (up to 5000 calorie diet) for 3 months and only gained 8 pounds.

We're planning to use brand name Coumadin for 90 days and see if it stabilizes INR fluctuations. I'm not taking any other medicines (except crestor and levothyroxine) and usually pretty consistent with my Vitamin K intake (rarely eat out), no alcohol either.

I guess the only variations are workouts, stress and weather.

My INR was stable for first 1 to 1.5 years after my surgery (i used to get my warfarin from CVS at that time), but last 1 year, has been different. I switched my pharmacy from CVS to Walmart in last 6 months.
 

Protimenow

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In my experience, it DOES make a difference who manufactures your warfarin.

A few years ago, Costco substituted another generic brand of warfarin, and I was unable to regulate my INR. I switched back to warfarin - the one I get is manufactured by Teva.

If they DO switch manufacturers on you, it may be a good idea to test after the third or fourth day and see if your INR changes. It did for me.
 

vivekd

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I may end up moving my pharmacy from Walmart to either Costco or CVS, after 90 day trial with brand name Coumadin.
 
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