Targets ... where do you shoot (and why)?

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pellicle

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Hi

using the target methodology (rather than the range) where do you aim?

1665962413438.png


myself I aim for 2.5 and choose to do nothing if I don't see a reason. A reason to me is a trend over weeks. If the trend is either elevating or consistently high then I readjust my scope a wee bit to account for that windage (or elevation) to keep my pattern around the center.

I know a few different strategies exist:
  1. do nothing unless its way high because its a PITA for no significant benefit
  2. make minor dose adjustments (perhaps in fractions of mg) as needed
  3. keep it lower and know it really isn't a problem unless its under 2 two measurements in a row and it'll pretty much never be higher than 3
I'd be keen to hear what people do and why (because discussion is always good on this topic; fresh perspectives n all).

Myself my approach has varied over the years so I'm a shoe in for #2.
 

Unicusp

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Also 2.5 although OnX says I can go lower, after reviewing data (much of which you've provided thanks!) I feel it's the safer bet. I make very minor adjustments after testing weekly. I monitor the trend as well. For example, today I was at 2.2 and last week at 2.3, so I made a minor upward dosage adjustment to get me back closer to 2.5 or slightly higher.
 

tommyboy14

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How do the two of you decide by how much to vary the dose by?

@pellicle I have seen you use a regression model before. Is that how you decide what the right change in dose is?

Or does this just come with experience?
 

leadville

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I aim at 3.0, ST jude AV

I generally try not to alter my dose unless my data shows a definite trend.

I'll then titrate accordingly.

To use Dick's quote ? :
A steady hand on the tiller is needed.
 
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ATHENS1964

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My target is 2.5 if I see that it increases for example 2.7 then 2.9 I increase the intake of vitamin K from salads if I see 3.1 I reduce the dose. When it is below 2.5 e.g. 2.3 if I had eaten food with a lot of vitamin K I adjust my diet to the usual pattern if my diet in the previous days was the usual one I slightly increase the dose
 

ATHENS1964

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For example, in the attachment we see the weeks and measurements, in general I prefer to be close to 3, the weeks I was more than 3 I don't consider them to have gone too far off target
week 2 reduce vitamin K
week 4. increase dose
week 5 reduce vitamin K
week 16 increase dose
week 31. reduce dose
week 35 increase vitamin K
 

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Unicusp

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How do the two of you decide by how much to vary the dose by?

@pellicle I have seen you use a regression model before. Is that how you decide what the right change in dose is?

Or does this just come with experience?
I think with experience as people react differently to varying doses of Warfarin. I factor in my diet over the previous week to see if that may have had any significant impact. When I recently traveled, I took some Airborne vitamin mineral supplements and they helped reduce my INR. I'm on a low dosage of 2.5 to 3 mg/day so when INR needs slight increase, I'll increase dosage by 1/2 mg/day for days needed to increase. It varies. But I find it to be very easy, intuitive and consistent.
 

tom in MO

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I go for a target range: 1.8-2.8. Take action if outside range. My clinical range is supposed to be 2-2.5. A target implies there is one best INR which is false. I like to keep it a range, since that's all science really knows.
 

gerrychuck

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My range is 2.5-3.5 and I aim for as close to 3 as possible. I react very differently when my INR is close to the lower limit of my range than when it goes high, simply because my experience has been that when it trends low it will usually come back toward the target without intervention, but when it goes up it tends to continue until it pops out of range if I don't change the dose. I adjust dosage by increments of 1 mg and will differ from my normal 6mg from 1 to 3 days/week to keep things balanced, although if I test out of range I will make a bigger adjustment. Still trying to train myself to stick with the smaller adjustments and be patient. But heck, it's only been 10 years, so I might get the hang of this yet!
 

pellicle

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How do the two of you decide by how much to vary the dose by?

@pellicle I have seen you use a regression model before. Is that how you decide what the right change in dose is?

Or does this just come with experience?
Hey ... I missed this but saw your quote from @Unicusp

Strictly speaking its not a regression analysis and not quite a stochastic method either, but it does incorporate elements of those. Yes its how I make the choice on what to do and by how much to respond.

As I've felt we have had unproductive and disrespectful communications in the past I'm not entirely inclined to discuss the model with you. However the "inner heuristic" (or getting a feel for it) is usually pretty good. I just wanted to take the extra steps and develop a data model for it so that it can be more automated and surrounded by what amounts to a science based Decision Support System from the data.
 

tom in MO

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How do the two of you decide by how much to vary the dose by?

@pellicle I have seen you use a regression model before. Is that how you decide what the right change in dose is?

Or does this just come with experience?


For me it came from my experience with the coumadin clinic. If I went out of range a little, we just tested again in a week.. If I went out of range significantly, say 2.5 to 2.9 we adjusted by taking a 1/2 dose and tested again in a week. If I went low to 1.8, the adjustment was an additional 1/3 or if 1.7 an additional 1/2. I do the same now that I self-dose.
 

Jamey T

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I don't try to micro manage my range. I live my life, and I make adjustments if I am out of range. I eat and drink what I want and don't even consider what it might do to my readings.

That being said, my life is fairly consistent. Some would call it boring, I don't. :)
 

Mister_James

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Some of y'all get really clinical with this. I saw @pellicle spreadsheet. I don't keep data of my INR I only remember my last one and the number I am looking at.
Why? It is very hard once you have been in range for a while to move out of range without some "work" on your part.
I am on a 7.5/7.5/5mg schedule. So there is weeks I have more mg. If my last reading was 3.2 and I am now testing 2.7 and it's my 5mg day, I will take 7.5 then 5mg next day and restart my cycle until the next test. Very small adjustments.
If my next test I am 2.5. I will restart my 7.5mg cycle that day regardless of where I was previously.
I will not make adjustments on my diet or dose my diet. Any one singular indulgence will not change your numbers. Now if you are aiming for 1.5 INR, you have some work.
I live comfortably between 2.0 to 4.0 but aim to be close to 3. My clinic gets a 2.8 report regardless of what the actual number is.
I test every other week.
 

Chuck C

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The range given by my cardiologist is 2.0 to 3.0. I use to target 2.5, the center of my range. However, since I started Jiu Jitsu again about 8 months ago, I have tightened up my range and like to be 2.0 to 2.5, so I target 2.3 to 2.4. This is to minimize the risk of have a bleed while I train. It is remarkable to me how often I am spot on at 2.3 to 2.4, which would not be possible if I did not self manage. If I find myself at 2.2 to 2.5, I will leave it alone, but if I get down to 2.0 or 2.1, I will adjust just a little, as I want to stay away from the danger zone of less that 2.0. If I'm at 2.8 to 3.0, I will adjust down a little and will not train hard until I confirm that I am back under 2.5.
 

Timmay

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The range given by my cardiologist is 2.0 to 3.0. I use to target 2.5, the center of my range. However, since I started Jiu Jitsu again about 8 months ago, I have tightened up my range and like to be 2.0 to 2.5, so I target 2.3 to 2.4. This is to minimize the risk of have a bleed while I train. It is remarkable to me how often I am spot on at 2.3 to 2.4, which would not be possible if I did not self manage. If I find myself at 2.2 to 2.5, I will leave it alone, but if I get down to 2.0 or 2.1, I will adjust just a little, as I want to stay away from the danger zone of less that 2.0. If I'm at 2.8 to 3.0, I will adjust down a little and will not train hard until I confirm that I am back under 2.5.

How often are you testing now Chuck? Curious if you're testing more than once a week because of the training concern.
 

Timmay

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I do #2

My target is 2.7528900132. As you can tell, I am a tinkerer. I mod stuff. I like playing around. I like learning (and for me playing around causes learning).

I received my Warfarin 101 class from @pellicle. I think he probably teaches the Warfarin 503 class too ;).

I test 1-2 times a week. Always on Sundays. A lot of times I test on Wednesdays too. I'm on 11mg / day. That said, lately I have been doing 11 and 10.5 alternating.

I eat whatever I want except for full 100% cranberry juice. I take Vitamin K. Some is in my Multivitamin but I also take another 100mg of K2 every day. Seems to help buffer things ... but what do I know? I only went to the 101 class 🤣😁
 

Chuck C

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How often are you testing now Chuck? Curious if you're testing more than once a week because of the training concern.
I do test a little more often than once per week on average now. Aiming for 2.3 to 2.4, I don't worry if I am 2.5 or 2.6 and will stick with weekly. However, in that I am at the lower end of my range, I do sometimes see 2.0-2.2. This this event, I would make a very small warfarin adjustment and test again in 4 to 5 days. I try to be very mindful not to let it drop below 2.0.
 

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