Need advice...

[realkarl]

My INR has been rock stable at 31.25 mg/week, but after spending 10 days in Norway, with a different diet and different (lower) activity level over Christmas, I dipped from 2.2 to 1.8 in a week. Normally, I would increase 10% and aim for a higher target, but I am going back to my standard routine on Jan 6th (back in the U.S.), and I am having a PM implanted on Jan 11th, where they want my INR < 2.5, no heparin or bridging plan.

So I am thinking a should take an additional amount right now, and continue at my normal dosage, at least until after the implant. They asked me to check my INR on 1/6, a day before my pre-implant doctor checkup on 1/7, and meeting with anti-coag nurse to set up a plan for the Warfarin dose the days before the implant. The last time I spoke with them, they expected to just continue my normal dose, since I had been so stable.

Any ideas how much is needed to increase my INR about 0.5, when my weekly dose is 31.25 mg (5mg x 4 + 3.75mg x 3)?

 

[Ross]

I wouldn't do anything. If your going back to normal and you adjust now, you'll start the teeter totter in progress. Just let it ease back into the norm.

 

[catwoman]

Karl:
This is just an uff da thing!

Ross is right. Your INR has dropped because of the change in your normal routine, eating habits, etc.
It should return to about the same levels when you resume normal schedule, etc.

Hope your trip to Norway has been great. My niece's great-grandparents (Knudsens) were Norwegians who immigrated to Cranfills Gap, Texas. Holly accompanied her grandmother to Norway about 9 years ago on a trip sponsored by a Lutheran church. Said there were lots of waterfalls. She went in August. Can't imagine going in December!

 

[realkarl]

Thanks for the great advice! Couldn't have been easier...

I go home to Norway every Christmas to 0-10F, with lots of snow, just the way winters are meant to be, but I have to admit, it feels colder than I remember every year

Wonderful winter weather in Gjøvik, 10F, frost smoke over Mjøsa, 12/31/2009

 

[Bina]

Karl, from what I understand, you are still in Norway for another few days?
In that case, I would bump up todays dose by a smidge to prevent a further drop...1.8 is not a place I would like to linger at. It is simple enough to decrease the smidge once you are back at home.

 

[Ross]

Karl, from what I understand, you are still in Norway for another few days?
In that case, I would bump up todays dose by a smidge to prevent a further drop...1.8 is not a place I would like to linger at. It is simple enough to decrease the smidge once you are back at home.

He could, but it's only 4 days away and has a procedure coming up that he needs a lower INR for anyhow. That is why I'd do nothing and simply let things come around on their own.

 

[Bina]

Ross, I'm not much of a gambler.... if Karl tests again on Monday and has dropped further, for example 1.6, he would be in a risky spot.
Oh well, we all do what we are comfortable with.

 

[Philip B]

Dosage Adjustment

Dosage Adjustment

It's interesting that you've seen a drop in your INR that seems to have accompanied a drop in the level of activity which has accompanied your trip to Norway. Normally, I see a rise in my INR if my activity level drops...slower metabolic rate translates to slower processing of coumadin through my system...in other words, it stays with me longer.

When I find myself out of range on the low side, I adjust my dosage to bring myself back up. Others may disagree with this perspective, but I never sit around and hope that things will simply just adjust on their own.

Where are those folks who always advise "dosing diet" rather than using diet to adjust INR? Some how advising someone to hold off making adjustments in dosage because he/she's changed eating habits while on vacation and will return to normal eating habits in a few days after returning home sounds like using diet to adjust INR.

It might be worth dropping your doctor an e-mail to get the input of a professional rather than relying on us amateurs for advice...you're looking at a surgical procedure in a few days...

-Philip

 

[Ross]

Where are those folks who always advise "dosing diet" rather than using diet to adjust INR? Some how advising someone to hold off making adjustments in dosage because he/she's changed eating habits while on vacation and will return to normal eating habits in a few days after returning home sounds like using diet to adjust INR.

It might be worth dropping your doctor an e-mail to get the input of a professional rather than relying on us amateurs for advice...you're looking at a surgical procedure in a few days...

-Philip

I'm right here Philip. Given the facts of the case, I myself would do nothing. He is obviously free to do as he sees fit and your right, were not professionals. I'd just hate to explain why all of a sudden his INR is going nuts because of a simple adjustment.

If you feel your in jeopardy, go ahead an bump it up by 10% for the week and test again. Just realize that when you get home and things get back to the REAL consistent normal, you'll likely have to back off some.

 

[catwoman]

Where are those folks who always advise "dosing diet" rather than using diet to adjust INR? Some how advising someone to hold off making adjustments in dosage because he/she's changed eating habits while on vacation and will return to normal eating habits in a few days after returning home sounds like using diet to adjust INR.

Karl's INR was only 0.2 under range for an aortic valve. This appears to be an isolated blip, which can be attributed to being on vacation. If he adjusts his dosage up now, he could find it too much.

I've had this happen. Gotten an INR of 2.3 out of the blue. I've just ridden it out until the next test to see if it's part of a trend. If I get another low reading like that, I adjust upward. Ditto with higher-than-normal INRs. I don't adjust based on just one test result.

Otherwise, it could become a yo-yo game.

 

[Lynlw]

I'm curious and this thread made me wonder, since he will be on a long plane trip, would it be better to be a little higher than lower, since people can get clots easier during long flights? I don't mean a big increase, but the smidge Bina was talking about to hopefully bring him over 2?

 

[Philip B]

Disagree?

Disagree?

Sorry to disagree Cat, but where the normal INR range zone for aortic valve replacements tends to vary among cardiologists. Your cardio doc and others may set the low end of the range at 2.0; mine sets it at 2.5.

When I drop below 2.5 my cardiologist expects me to make an adjustment to bring it up. He really doesn't want me to spend much time below 2.5. A drop below 2.0 would concern him. If I reported a 1.8, he'd be asking me what I did to fix the problem. While he's told me 2.0 offers some protection against clots, he feels the level of protection at 2.0 is minimal. This said, without a doubt, opinions vary among members of the medical community just as opinions vary among our membership.

I've never managed to get the yo-yo thing going simply by making small dosage adjustments to bring myself up, but that's just me. When I find myself outside my prescribed range I rely on coumadin to make the necessary adjustment rather than adjusting my diet or activity level, but again, that's just me.

How in the world would I (or anyone else) know why someone else drops out of range? Is the drop because of diet changes, activity level changes, hydration, dehydration, jet lag, or something else that has affected the individual's metaboic rate.

Sure, we can offer advice based on our experience, assumptions and the limited information we get from the individual who has encountered the drop. I guess I'm more comfortable seeing INR adjustment advice based upon things like dosing charts, but again...

-Philip

 

[realkarl]

Thanks for all the advice. I will of course also get the advice from a professional once they receive the result over the weekend.

I did take an additional 1.25mg yesterday (~5% weekly), for a tiny bump, and plan to continue the same dose as before until I hear otherwise from my anti-coag clinic or nurse, and it seems reasonable. I plan to test again on Wednesday. I am not a huge dark green eater, and don't plan to change that either.

As I have mentioned in another thread a while ago, with the On-X reduced/no Warfarin trial going on with no negative results to stop it early, it's very likely my adjusted range will be 1.5 to 2.0 sometime in 2011. Some aortic On-X patients may be able to stop Warfarin all together, but that will take longer to determine. So I am not overly worried being a little under 2.0 for a few days. I really don't want to cause too much of an increase and risk a procedure postponement, or bleeding trouble during or after. When I increased my dose 10% over where I am now in the past, I got up to 3 pretty quickly. After I reduced it back down again I have been stable since 10/22/2009.

Karl.

EDIT: with regards to activity level: this is hard to measure, and what I wrote about it being lower was just a feeling I had before I ran the test. I have exercised here as well, but a different kind, so it's hard to compare. I believe the blip is caused by diet, and perhaps a hint of a cold I had, but this is impossible to know.

 

[Ross]

The few reasons for my decision, which again, is not professional but that of someone that's dealt with this stuff for 9 years.

1. On-X valve=lower anticoagulation even if only in trial.
2. 1.8 is not enough to warrant a change, it may only be a one time test result and the next could very well be 2 or above.
3. Karl has a proceedure coming up where he needs his INR to be low.
4. Given he's in another part of the world, chances of his INR returning to normal will come right along with the jet lag from the trip home.

 

[realkarl]

Ross: your advice was spot on. With no dosage change, when I tested last Thursday, the day after my return, my INR was 1.7 in the morning, and 1.9 in the evening when tested at the lab. Then, I figured it was a good idea to test Saturday evening at home, due to the travel from continent to continent, and when it was 2.0, I took 1/2 dose that night, with the upcoming Monday procedure. That turned out to be wise, since the INR was 2.2 this morning, when they measured before the PM implant. There were no bleeding complications, and now I will continue the same dose as before, and test again in a week, since I will have to lower my activity level a few days. If I had increased my daily dose, it's quite likely I would have ended up above 2.5. What is it with Seattle, vs Norway...? The temperature, for one, but I am not spending much time outdoors in -20F anyway..

 

[Ross]

Just watch that you don't fall too low now. I don't think you will, but INR is INR and sometimes has a mind all it's own.