my self management results for 2020

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ATHENS1964

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What kind of lettuce Pellicle? I use iceberg (low vitamin k) with heart of romaine.
I would love to indulge in mixed greens and butter lettuce. Both high vitamin k.
Also I love avocado but I avoid because of vitamin K. I bought a book called “the Coumadin cookbook” . Written for warfarin patients last edition 2005. It says BEWARE OF AVOCADO. It says vitamin k content in it can vary as much as 40 times! And that small amounts can alter INR.
 

pellicle

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Hi there

What kind of lettuce Pellicle? I use iceberg (low vitamin k) with heart of romaine.
well it doesn't matter, and iceberg is the lowest in vitamin K, so you could eat that until you could not swallow another bit and still make no significant impact on your Vitamin K.

Basically the darker the green the more the Vitamin K (rule of thumb)

I would love to indulge in mixed greens and butter lettuce. Both high vitamin k.
well ingulge and err ... both are not high in Vitamin K compared to spinach. Kale is a little higher than spinach

Also I love avocado but I avoid because of vitamin K. I bought a book called “the Coumadin cookbook” .
my advice is throw it in the bin, because its just plain wrong. Its written by nutritionists who are barely a step above the general public. Meaning ignorant of the facts.

1614718481699.png


a whole cup of romaine lettuce is 61micrograms as you saw earlier you need to have 2milligrams of Vitamin K (1milligram {mg} = 1000microgram {mcg})

so to get 2mg of Vitamin K you'll need to eat 33 cups of lettuce. In a sitting.

Lets examine avacado

1614718128940.png


This government source lists it at 21micrograms per half.

and so you'd need to eat 47 whole avacados in a sitting to get an INR change of significance.

It says BEWARE OF AVOCADO. It says vitamin k content in it can vary as much as 40 times!
... are you seeing my point yet? Dieticians are very nice well meaning people but don't have a fundamental grasp on drug issues. They don't even have much of a grasp on nutrition either, as if you read books from the 60's it often is contradictory to books now. To a pharmacologist they are just like children reading story books.

So eat what ever you like (not cranberry or grapefruit) and you're sweet.

best wishes
 

ATHENS1964

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Today as an accompaniment I have 2 pieces of spinach pie and various herbs.
It was made by the wife with a sheet that she made , I estimate that spinach is about a cup of tea .
1614746613389.png
 

Sheenas7

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In cardiac rehab about 8 years ago I was told that book is out of date. We were told the modern philosophy is to dose the diet these days and no longer diet the dose. I was told that the "special coumadin diet" is an older philosophy found to be incorrect.

I eat avocados w/o any problems with my INR. Per HealthLink British Columbia, an avocado has 40 ug of Vit K, a cup of lettuce has 60 ug with a 1/2 a cup of mustard greens at 438ug. I eat all three without problem. One would think the mustard greens should send me over the edge. Maybe that's because although greens has 10x as much Vit K, it's harder to digest. I don't know.

One thing I am sure of, if you see published values for Vit. K w/o a reference to a reliable source...don't believe it. If it has a reliable reference, check the reference to see how the values were obtained. Testing food for vitamins has a variety of variables from the soil conditions, plant species, local environmental conditions, harvest method, post harvest handling, sampling and sample processing before it even gets to an instrument for analysis. Plus, a serving may have Vit K, but that doesn't mean your digestive system will deliver it all to your cardiovascular system.
I am going to try a bit of avocado 🥑😊
Hi there



well it doesn't matter, and iceberg is the lowest in vitamin K, so you could eat that until you could not swallow another bit and still make no significant impact on your Vitamin K.

Basically the darker the green the more the Vitamin K (rule of thumb)



well ingulge and err ... both are not high in Vitamin K compared to spinach. Kale is a little higher than spinach



my advice is throw it in the bin, because its just plain wrong. Its written by nutritionists who are barely a step above the general public. Meaning ignorant of the facts.

View attachment 887591

a whole cup of romaine lettuce is 61micrograms as you saw earlier you need to have 2milligrams of Vitamin K (1milligram {mg} = 1000microgram {mcg})

so to get 2mg of Vitamin K you'll need to eat 33 cups of lettuce. In a sitting.

Lets examine avacado

View attachment 887590

This government source lists it at 21micrograms per half.

and so you'd need to eat 47 whole avacados in a sitting to get an INR change of significance.



... are you seeing my point yet? Dieticians are very nice well meaning people but don't have a fundamental grasp on drug issues. They don't even have much of a grasp on nutrition either, as if you read books from the 60's it often is contradictory to books now. To a pharmacologist they are just like children reading story books.

So eat what ever you like (not cranberry or grapefruit) and you're sweet.

best wishes
thank you!!!
 

Chuck C

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Hi there



well it doesn't matter, and iceberg is the lowest in vitamin K, so you could eat that until you could not swallow another bit and still make no significant impact on your Vitamin K.

Basically the darker the green the more the Vitamin K (rule of thumb)



well ingulge and err ... both are not high in Vitamin K compared to spinach. Kale is a little higher than spinach



my advice is throw it in the bin, because its just plain wrong. Its written by nutritionists who are barely a step above the general public. Meaning ignorant of the facts.

View attachment 887591

a whole cup of romaine lettuce is 61micrograms as you saw earlier you need to have 2milligrams of Vitamin K (1milligram {mg} = 1000microgram {mcg})

so to get 2mg of Vitamin K you'll need to eat 33 cups of lettuce. In a sitting.

Lets examine avacado

View attachment 887590

This government source lists it at 21micrograms per half.

and so you'd need to eat 47 whole avacados in a sitting to get an INR change of significance.



... are you seeing my point yet? Dieticians are very nice well meaning people but don't have a fundamental grasp on drug issues. They don't even have much of a grasp on nutrition either, as if you read books from the 60's it often is contradictory to books now. To a pharmacologist they are just like children reading story books.

So eat what ever you like (not cranberry or grapefruit) and you're sweet.

best wishes
"and so you'd need to eat 47 whole avacados in a sitting to get an INR change of significance."

I think I'll try eating about 20 of them first and test my INR to see if I can eat that many 🤣

Great data on greens and avocados and I'm really glad that avocados are still on the menu! I eat at least half an avocado every day and sometime a whole one. I was an avocado farmer in Fallbrook for 8 years and never got sick of eating them.
 

ATHENS1964

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"and so you'd need to eat 47 whole avacados in a sitting to get an INR change of significance."

I think I'll try eating about 20 of them first and test my INR to see if I can eat that many 🤣

Great data on greens and avocados and I'm really glad that avocados are still on the menu! I eat at least half an avocado every day and sometime a whole one. I was an avocado farmer in Fallbrook for 8 years and never got sick of eating them.
Sometimes I melt avocado with a little garlic and a little oil, incredibly tasty with bread
 

ATHENS1964

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I had some last night! Yummy!
See the link below, you can have all the information about all the food .

I saw in the link that it says Vitamin K (phylloquinone) 21 µg Vitamin K (Dihydrophylloquinone) 0 .g Does anyone know the differences and what measurement are we interested in?
 
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pellicle

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Chuck C

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INR
Warfarin (daily mg)​
average
2.6
7.0516
std dev
0.3
0.3
max​
3.4​
7.5​
min​
1.5​
6.0​
over event​
1​
under event​
1​
inRange %​
96.4​

Thanks again for sharing your great results from self monitoring your INR. As you know, I am getting surgery soon and am heavily leaning towards going mechanical. Your data is really helpful as I try to imagine what life will be like on warfarin and gives me confidence that I will be able to self manage and live a normal life.
I was going to start a new thread on this topic, but since this thread has become such a robust discussion about INR management, I thought I would post about some observations, thoughts and questions that I have about the subject.
One thing I am trying to establish is how much my life will be different on warfarin compared to now. Some activities will be off the list, like my boxing. But, also lifestyle. I am not a heavy drinker, but on occasion I do like to have a few. Had 3 glasses of wine with the wife last night. Every now and then that is fun. A few times per month I like to watch the fights at the sports bar(that's pub for some of you) and on those occasions, I will often drink about 6 light beers over the course of 3 hours. I don't like to get drunk, but its enough to keep a buzz and I happen to really like to do that at times. Now, if I listen to some of the doctors giving guidance on drinking alcohol on warfarin, it goes something like this:
"It is best if you don't drink alcohol while on warfarin. But, if you must, never have more than 1 drink. And, whatever you do, do not have more than 2 drinks or you just might die."
Interesting, never once have I found such guidance reference any scientific literature on the subject. And, when I read the numerous threads about the subject on this forum, Pellicle and many others share how they often have a few drinks and guess what?...... they don't die. And beyond that, there seems to be very stable INR readings- certainly in Pellicle's case despite the fact that he likes to throw a few back. Some even report that they go on a bender from time to time, and even they don't report that they have died from it. Ok, I know, participation bias in that only those who survive the bender live to comment on the subject. ;)
But, when I search for the evidence, while I did find literature to support that there is an uncommon genetic variant which does cause a person's INR to move significantly from alcohol consumption: Those with VKORC1 1173 C>T, CYP2C9*2 and CYP2C9*3 variant polymorphisms.
For those nerds among us here are some publications on those genotypes:

It seems that this is not present in the vast majority- one study found it to be about 4.2%, linked above. That was among Romanians, which the study indicated was similar to other European populations, but it is found less often in other groups. This seems to make sense, in that most here report no big move in INR from alcohol, but Eva has indicated that hers moves significantly. This is what one would expect from such a distribution.
A conclusion from one of the studies above, which I find interesting given that such a small percentage of this population has this genotype:
" The study also has important implications for improving medication safety. Warfarin had a black box warning about concomitant use of alcohol, but that warning was removed, potentially because of lack of evidence to support the risk of alcohol–warfarin interactions. This study suggests that patients should be warned about alcohol-related warfarin risks. "
Translation: because a very small percentage of the population might get an increase in INR from alcohol, rather than acknowledge that all patients vary and treat our patients like adults, trusting them to establish how alcohol affects their individual INR- give blanket warnings of gloom and doom should you ever dare to drink alcohol.

As I've tried to understand why alcohol makes INR go up for some- the explanation goes something like this based on my reading of the literature- I apologize if this is over simplified: Our liver clears warfarin from our system. When we drink, our liver also now has to contend with clearing alcohol from our system. This causes the liver to be not as effective at clearing warfarin for awhile, especially for some individuals, and can cause warfarin and INR to be elevated for a time. This should not pose a problem for people who drink about the same every day, or whose livers clear medications from their system in a normal way. But, if you have a genetic variant that predisposes your liver to not being able to clear things as well, the alcohol may cause large increases in your INR, especially if you drink erratically.

Here is what I found to be the most comprehensive published paper on the subject attempting to correlate the degree of alcohol consumption to INR above target range. The findings were interesting, but I think not too surprising: In the intro they state: " With regard to warfarin, some, but not all, authors recommend alcohol be avoided completely." Yes, completely.
The study broke the participants into 4 groups depending on their level of alcohol consumption: non-drinkers, light, moderate and heavy. Here is what they found:
" The dose of warfarin required to maintain goal INR levels tended to be slightly higher among men with greater alcohol consumption. " Not surprising. But it also found something that I find even more interesting, but perhaps, not really surprising, unless one subscribes to the guidance that tells you don't drink or you will die: The study found that it did not matter if someone was a non drinker, light drinker, moderate drinker or heavy drinker. There was no correlation between the level of alcohol consumed and the number of INR readings above target, except that heavy drinkers were over INR target less than any of the other groups.
" We found no clear relation between alcohol use and maximal INR levels or the risk of an INR of 2.0 or higher. " (target INR was 1.8 to 2.0)
Results: “ The risks of an INR of 2.0 or higher were 67%, 66%, 68%, and 61% among non-, light, moderate, and heavier drinkers”
Yes, you read that right. The heavy drinkers were over the INR target less than any of the other groups. I am certainly not advocating heavy drinking, but results are results.
Interesting, the researchers could not bring themselves to title their study honestly nor could they bring themselves to say out loud in the conclusion what the results found. Their conclusion was the following: " In summary, among men who had undergone previous CABG surgery, we found little evidence that moderate alcohol use affects the safety of either lovastatin or lowdose warfarin as measured by ALT and INR levels. " The bold is mine. In truth, they found that no level of alcohol consumption affected the INR, but hey, we sure don't want to even give the appearance of promoting heavy drinking do we, so, let's just leave that part out. There is definitely an anti-alcohol bias in medicine. Like I said, I don't advocate heavy drinking, but don't treat us like children and twist the conclusions of your studies to suit your anti-alcohol bias please.

Here is the study:


Here is another study which actually found that moderate drinking had a benefit in controlling INR: "Higher vitamin K intake (OR, 0.7; 95% CI, 0.5-0.9) and habitual alcohol consumption of from 1 drink every other day to 2 drinks a day (OR, 0.2; 95% CI, 0.1-0.7) were associated with decreased risk. " for ".... factors independently associated with an INR greater than 6.0"


The data and the feedback here on this wonderful forum seems to suggest, if you drink moderately, you will probably still be able to drink moderately on warfarin. If you like to throw a few back on special occasions, that is probably going to be just fine too.

A question. If a person did find that their INR shot up after having a few drinks in the evening, couldn't adjustments be made to try to stabilize outcomes? For example, let's say mine shoots to 4.0 after drinking a few. With the idea that this is caused by having a little extra circulating warfarin due to delayed processing in the liver, doesn't it make sense that one should be able to plan ahead, through trial and error, and find a way to tweak dose prior to drinking say, drop 1/2 mg for a day or two prior to the big event?

Now, please excuse me. There is an exciting line up for the UFC fights today and I need to make a beer run before they start. I think I'm going to be just fine on warfarin and, if I am one of those genotypes whose INR goes up a lot, I guess I will just have to figure it out.
 
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pellicle

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Hi

Thanks again for sharing your great results from self monitoring your INR. As you know, I am getting surgery soon and am heavily leaning towards going mechanical.
just so that you know, that was over 1500 words, quite an essay and very difficult to pick what questions were.

If I can propose that you follow a method like:

you proposal

supporting evidence​

[question if one exists]

note the paragraph breaks too ... they turn a slab of text into something which people can read.

so ...

I thought I would post about some observations,
thoughts and questions that I have about the subject. One thing I am trying to establish is how much my life will be different on warfarin compared to now. Some activities will be off the list
I thoght that this was pretty well established, aside from regular head strikes designed to knock you stupid to allow more head strikes (and body strikes designed to disable muscles to make it harder for you to strike back) - not much different at all. I have said on many occasions my life is no different at all with the exception of the minor amount of work I put into managing my inr.

I mean that in the fullest sense of the meaning of "no different"

But, also lifestyle. I am not a heavy drinker, but on occasion I do
like to have a few. Had 3 glasses of wine with the wife last night.
Every now and then that is fun. A few times per month I like to watch the fights at the sports bar(that's pub for some of you) and on those occasions, I will often drink about 6 light beers over the course of 3 hours.
as has been discussed here many times this is literally a nothing. It will make no difference to you unless you fall down the stairs and smash you head (or break your neck).

Interesting, never once have I found such guidance reference any
scientific literature on the subject.
because 1) its not a particularly scientific question and 2) its of little interest to anyone in the community who reads that. In the science world getting publications is one thing; getting read and cited in others is another. As nobody is likely to do 1 or 2 above then there is the dearth of papers.

Then there is the fact that so many people have such disparate reactions to booze that it makes the results meaningless.

I'm quite sure you must know some 2 pot screamers as well as those who after half a bottle of Gin are cognisant (myself I tend towards the latter) as you yourself observe.

certainly in Pellicle's case despite the fact that he likes to throw a few back.
I'd say that there's at least a few others here (and some I know who no longer post but I help them with their INR).

I'd say that in general we know something about how alcohol is metabolised but we just do not know 100% of the data, why? because of 1 and 2 above. Its like car accidents, we don't study the effects of how many car accidents you can have and be unharmed, the "community" considers it better to avoid them.

1615063785373.png


However with alcohol I can say the following: Alcohol metabolism is relatively complex (not least because its also technically a source of energy and thus a food not just a toxin). There are (like everything else in life) many subtle variants of which metabolism The "heavy lifting is done by alcohol dehydrogenase, which (interestingly makes a toxin out of it; acetaldehyde. This is then attacked by aldehyde dehydrogenase ...

So while (as you later observe) this is done with compounds made by the liver it is not involving the all important (for warfarin) Cytochrome P450 pathway. You touch on this when you cite:

there is an uncommon genetic variant which does cause a person's INR to move significantly from alcohol consumption: Those with VKORC1 1173 C>T, CYP2C9*2 and CYP2C9*3 variant polymorphisms
notice the spelling? C Y ... Cytochrome?

from CYP2C9

CYP2C9 is an important cytochrome P450 enzyme, which plays a major role in the oxidation of both xenobiotic and endogenous compounds. CYP2C9 makes up about 18% of the cytochrome P450 protein in liver microsomes​

(I'll leave it to you to chase down the rabbit hole of what microsomes are), but do follow up on P450, the links to which are embedded.

Do you see that this question is quickly going sideways? Like a kid planting his foot on the pedal of a 5L V8 for the first time ...

Even constructing a worthwhile research question is fraught.

I'll go with your research question (which is really quite meaningless in your own context because you don't know which you are) of: As I've tried to understand why alcohol makes INR go up for some

When we drink, our liver also now has to contend with clearing alcohol from our system.
addressed above

This causes the liver to be not as effective at clearing warfarin for awhile
a simplification and ignoring many other issues but yes, you can liken it to how much you can do in a day. If your doing "the dishes" and you're now tasked with "cleaning the bathroom" then you can't do as much of both in the same time. Nor can your body clear more toxins at the same time. This results in a build up of one (deemed less important by your body; which is the warfarin).

This thus influences the clearance rates of warfarin which because you'll be taking some the next day. Remember your body clears it based on a rate, which we call the "half life" because its a "rate of clearance".

But, if you have a genetic variant that predisposes your liver to not being able to clear things as well, the alcohol may cause large increases in your INR
then you'll already be well aware of that with your normal response to alcohol ... do you get a red face quickly? Shocking hangovers from just a few?

The study broke the participants into 4 groups depending on their level of alcohol consumption:
  • non-drinkers,
  • light,
  • moderate and
  • heavy.

and

" The dose of warfarin required to maintain goal INR levels tended to be slightly higher among men with greater alcohol consumption. "
which is consistent with my above rationale

The study found that it did not matter if someone was a non drinker, light drinker, moderate drinker or heavy drinker.
because unlike muscle and fitness training you can't (or I have never seen or heard of it) train up your biochemistry.

There was no correlation between the level of alcohol consumed and the number of INR readings above target, except that heavy drinkers were over INR target less than any of the other groups.
because as the olde adage here goes "whatever you eat (or drink) do it consistently and there will be no effect on INR ...

it all boils down to homeostasis. I don't suggest you become a heavy regular drinker because that will effect your health over time.

Their conclusion was the following: " In summary, among men who had undergone previous CABG surgery, we found little evidence that moderate alcohol use affects the safety of either
lovastatin or lowdose warfarin as measured by ALT and INR levels. "
the very thing we've (us drinkers) all been saying all this time. But its good to get some sort of external validation and not just trust us (we could all be colluding and lying to you).

In truth, they found that no level of alcohol consumption affected the INR
no, that is not what they found and that's "loose with your words" ... such will lead to incorrect extrapolations. You must be tight in your use of words, just like the use of your arms in boxing.

{as there is a lot see part 2}
 

pellicle

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part 2


A question. If a person did find that their INR shot up after having a few drinks in the evening, couldn't adjustments be made to try to stabilize outcomes?
no because of the facts that I discussed here:

specifically:
The half-life of racemic warfarin ranges from 20 to 60 hours. The mean plasma half-life is approximately 40 hours, and the duration of effect is two to five days.

So the influence of the alcohol will be gone before you can realistically make any observation of the effect and cater for it. You can (if you are the micro managing type) go to the trouble of anticipating and correcting by making a dose reduction in advance, but for what possible gain?

Remember that the entire INR thing is a statistical thin, you will not turn into a puddle of blood if your INR goes over 3 (or even 5) for half a day. If you're smart you'll take a day of rest after a night of heavy drinking (and man, 6 light beers? Really? I'd call half a bottle of bourbon a heavy night (yes, that has happend)).

For example, let's say mine shoots to 4.0 after drinking a few.
whoop-di-doo! Have you forgotten this graph already?


As you see, 5.4 and no significant increas in risk. Do you think those numbers were transients or "on that INR for about a week"?

I think I'm going to be just fine on warfarin and, if I am one of those genotypes whose INR goes up a lot, I guess I will just have to figure it out.
agreed, and I hope that from this discussion you see:
  1. if you were one of "them" you'd probably already know
  2. if you are somehow sensitive you'll work it out
  3. you don't seem to drink enough to be a "heavy hitter" on hitting the booze (6 light beers in 3 hours ... clearly you're an athlete not a regular drinker)
  4. you can stand down on the heavy analysis and over thinking because its not doing much and I feel you've got your axle up on axle stands and gunning the motor furiously and not getting anywhere (recovering old ground, which is fine too).
Best wishes
 

Chuck C

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whoop-di-doo! Have you forgotten this graph already?




Thanks. I appreciate the thorough response. As I have said before, I really appreciate that graph with INR and correlating events. It really shows where the danger is and how few events happen within the target zone. It also shows that there is considerable margin between the target zone and the danger zone. As you point out, even at 5.4 INR there is no significant increase in risk. So, if a night of drinking puts someone above target, say puts them at 4.0, it would seem to be no reason for panic and not really near the danger zone at all, as INR of 4 really does not have any more events than 2.5-4, at least per the data in the study you cite.
" 6 light beers? Really? I'd call half a bottle of bourbon a heavy night (yes, that has happend)"
Well, I may have been rounding down a bit- don't want to come across as a lush or anything. I've had 10-12 plenty of times :)
And you point is well noted about the half life of warfarin. I can really see how doing self management is a real advantage. In that INR tends to move slowly, it gives you a chance to adjust before things get bad. On the other hand, if someone is dependent on getting their readings at the clinic, they might be in the danger zone for weeks before they realize it.
"So the influence of the alcohol will be gone before you can realistically make any observation of the effect and cater for it. You can (if you are the micro managing type) go to the trouble of anticipating and correcting by making a dose reduction in advance, but for what possible gain?" Great point.

Thanks again.
 

pellicle

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@Chuck C

I feel that you're following a pathway like this with respect to your confidence in your decision process:

1615076615517.png


but perhaps because you don't have a baseline on where your confidence started from each time you feel a drop back in confidence (that this is right) you may not notice that you're actually always stepping up in confidence, and the the fall is just relative.

Make no mistake, there is nobody here (that I know) who'll disparage you in anyway if after surgery you announce you picked a tissue prosthetic. It is always your choice and everything I say is about my views of the general question of "what I think is best to do for what I know of you".

Best Wishes

PS; where you said:
they might be in the danger zone for weeks before they realize it.
the problem is compounded like this:
  1. how frequently are you being tested (weekly - good, bi-weekly - not so good, monthly nearly no point, yearly - hardly different), depending on that you may know if your high and going lower or high and going higher (that would mean weekly and shifting to an AdHoc test mid week to see)
  2. any delay in telling you the results will make this process more difficult (picture saying "left, right, slow down" instructions to someone blind steering a car).
  3. there are always small things which occur which steer your P450 pathway and its clearance, its NOT a rock nor a computer program, its all biological; and just like how confident / how together / how coordinated you feel on any given day will change it will too ... its biological.
  4. the sooner you can get test results and then (at your discretion schedule another test ("hey" I say to myself looking at my Coaguchek, "we should schedule another test on Wed") the sooner you can know if you should:
    * just keep it steady (as its returning without assistance)
    * give it a smack on the arse with a single dose correction
    * make a broader dose adjustment (eg typically ±0.5mg per day) to keep it steering in the right direction
Have a glance through this post again with that "simple harmonic motion" of biological systems in mind

 
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Chuck C

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@Chuck C

I feel that you're following a pathway like this with respect to your confidence in your decision process:

View attachment 887608

but perhaps because you don't have a baseline on where your confidence started from each time you feel a drop back in confidence (that this is right) you may not notice that you're actually always stepping up in confidence, and the the fall is just relative.

Make no mistake, there is nobody here (that I know) who'll disparage you in anyway if after surgery you announce you picked a tissue prosthetic. It is always your choice and everything I say is about my views of the general question of "what I think is best to do for what I know of you".

Best Wishes

PS; where you said:


the problem is compounded like this:
  1. how frequently are you being tested (weekly - good, bi-weekly - not so good, monthly nearly no point, yearly - hardly different), depending on that you may know if your high and going lower or high and going higher (that would mean weekly and shifting to an AdHoc test mid week to see)
  2. any delay in telling you the results will make this process more difficult (picture saying "left, right, slow down" instructions to someone blind steering a car).
  3. there are always small things which occur which steer your P450 pathway and its clearance, its NOT a rock nor a computer program, its all biological; and just like how confident / how together / how coordinated you feel on any given day will change it will too ... its biological.
  4. the sooner you can get test results and then (at your discretion schedule another test ("hey" I say to myself looking at my Coaguchek, "we should schedule another test on Wed") the sooner you can know if you should:
    * just keep it steady (as its returning without assistance)
    * give it a smack on the arse with a single dose correction
    * make a broader dose adjustment (eg typically ±0.5mg per day) to keep it steering in the right direction
Have a glance through this post again with that "simple harmonic motion" of biological systems in mind

That is a very valuable blog post about INR management. I plan to refer to your data and feedback often. You are truly the INR management guru!
 

ATHENS1964

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Last photo that I upload with the salads my lunch , purpose was to show that everything can be done, today is the measurement.
 

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