Up and down INR!?

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Chuck C

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anyone in the USA see these warnings about grapefruit? It sure ain't on my bottles
I was on statins for years and was aware that grapefruit would interfere with them and to avoid. I don't remember if it was in the paper or if I read it online somewhere. So, I've been avoiding the stuff for years and am happy to continue to avoid it.
I don't think it is on the bottles, but they always give a lengthy insertion with each prescription- several pages of warnings and such. It may be in there, but I'd wager than less than 5% of folks read the inserts.
 
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pellicle

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oops


Folklore has suggested that consuming grapefruit may promote weight control. Sparse data exist to support this hypothesis, although there is some evidence of health promotion effects with regard to blood pressure control and modulation of circulating lipids. The aim of this randomized controlled trial was to prospectively evaluate the role of grapefruit in reducing body weight and blood pressure and in promoting improvements in the lipid profile in overweight adults (N = 74).
...
This study suggests that consumption of grapefruit daily for 6 weeks does not significantly decrease body weight, lipids, or blood pressure as compared with the control condition. However, the improvements in blood pressure and lipids demonstrated in the intervention group suggest that grapefruit should be further evaluated in the context of obesity and cardiovascular disease prevention.​
 

Chuck C

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but is it on your warfarin packets?
Just checked. There is no warning on the bottle, just a warning not to get pregnant while on warfarin. I'll have to make sure that I don't. 🤣
It does have a warning with an instruction to "Read the medical guide included in the package." There is a good chance that it would be in there, as those generally are several pages long. If I can remember, I'll make a point of checking the guide the next time I get a refill, which won't be for a couple of months.
 

Chuck C

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but is it on your warfarin packets?
Ok, I found a link which has the general warfarin information and warnings. I believe that this is the current information that is included in the Medication Guide that they include in the bag each time they fill the prescription.

It does mention grapefruit:

" Some botanicals and foods can interact with COUMADIN through CYP450 interactions (e.g., echinacea, grapefruit juice, ginkgo, goldenseal, St. John’s wort "

 

pellicle

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Ok, I found a link which has the general warfarin information and warnings.
so there was a link on the packet, which you had to type in to get to that page ... pretty hard to argue that this "makes it clear to the patient".

Reminds me of the Hitchhikers Guide to the Galaxy

... just sayin :)
 

Chuck C

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so there was a link on the packet, which you had to type in to get to that page ... pretty hard to argue that this "makes it clear to the patient".

Reminds me of the Hitchhikers Guide to the Galaxy

... just sayin :)
It’s actually a paper insert that they give us with prescriptions. The link I gave appears to mirror the inserts we get.
but the inserts are long and the information is hard to find and as I said above, I doubt more than 5% of patients actually read them.
it seems that there are a few things that are so common, such as grapefruit juice, that they should make the warning very clear and impossible to miss. And how about if the pharmacist gives you a verbal of the most dangerous supplements and foods to affect your INR? That would probably be more effective
 

pekster11

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So......

I tested myself this morning with my Coaguchek INRange meter...I got 5.8 !!!! :oops::oops:
I thought there must be something wrong with either the meter, the testing strips or my technique !!

Went to the INR clinic about an hour later and had blood withdrawn from a vein to test INR
Results just back....5.6

Surgery rang me with the results

New dosage for the next week as advised by the surgery...today and tomorrow...no warfarin...after that 1mg per day, until results of next INR test (next week)

I haven't had any grapefruit juice since Saturday btw
What the F is going on !!! :(:confused:
 
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leadville

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At least that lab comparison will give you confidence in your meter .
Unlucky situation it might take a while to settle.
Before this you were stable so you will get there again.

Just one point ; you haven't recently had a warfarin brand change by chance to a generic ?

Just a thought.
 

pekster11

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At least that lab comparison will give you confidence in your meter .
Unlucky situation it might take a while to settle.
Before this you were stable so you will get there again.

Just one point ; you haven't recently had a warfarin brand change by chance to a generic ?

Just a thought.
no brand change since I started on warfarin after the op

this change in my INR has happened since I came back home 2 weeks ago
before that, after I was discharged from hospital I was living with relatives for a month

i think it's the change in diet and eating habits that has occurred in the past 2 weeks.
apart from the grapefruit juice, which i havent had for 5 days now, i'm scratching my head to think of what it could be though

can eating time and patterns affect INR ?

whilst at my relatives i would eat quite a large supper at 7pm
now i'm at home, i rarely eat much after 5-6 ish
 

Chuck C

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I tested myself this morning with my Coaguchek INRange meter...I got 5.8 !!!!
Went to the INR clinic about an hour later and had blood withdrawn from a vein to test INR
Results just back....5.6
So, the good news is that your Coaguchek is closely aligned with the lab results.

New dosage for the next week as advised by the surgery...today and tomorrow...no warfarin...after that 1mg per day, until results of next INR test (next week)
If it were me, I would test myself after the two days of holding your warfarin. Since you have your own Coaguchek and it seems accurate, I see no downside in testing. I know that many are in the testing weekly mindset, apparently even some clinics, but when your INR is going wild, in my view you want to test more frequently, so as to not overcorrect.
During my wild, amiodarone fueled, week, my INR went from 3.1 to 9.7, to 1.6 then to 5.6. The Coumadin Clinic had me down at the lab testing daily. They even had me test twice one day, as we wanted to see which direction things were headed within 4 hours after taking vitamin k.

Holding warfarin for two full days, then dropping to half a dose for several days seems like a very big reaction. It may very well be warranted, but it could result in undershooting your INR. For example, it is entirely possible, even if unlikely, that you could be under 2.0 INR after holding for two days. That would be very good information to know before going on half a daily dose for several more days before retesting.

Ideally, you want a gentle landing into range, rather than a yo yo week of undershooting then possible overshooting again.

I'm not saying not to follow their guidance, that is, of course, what you should do. But, having a bit more spot checking on how quickly your INR is moving won't hurt, in my view.

For what it's worth, during my wild week, when I was at 5.6, they had me hold for one day, then test again the next morning before deciding on whether to hold again or dose. It dropped significantly from the one day hold and they decided to dose me the next day, rather than have me hold for another day. I was soon in range, and you will be too.

It seems like you have had a bit of a wild week, almost certainly caused by the grapefruit. But, 5.6-5.8 is really not that alarming. When I hit 9.7 INR I was very concerned. I asked the clinic if I should check into the ER and get intravenous vitamin K. They said that they don't have patients generally do that until they hit 12 or 13 INR. They gave me a prescription for vitamin K and told me to just be very careful not to fall or hit my head for the next few days. Boxing was clearly off the menu.

So, your INR is a little out of range. But, the good news is that you and the clinic are aware of it and are taking action. You are relatively new to warfarin and it sounds like early fluctuations are normal, especially when adding something, like grapefruit, which interferes with how warfarin acts. Just be sensible and don't do anything likely to cause a bleed in the next few days and you should be back in range soon. Until then, put a hold on the machete juggling and sky diving :)
 
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pekster11

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So, the good news is that your Coaguchek is closely aligned with the lab results.



If it were me, I would test myself after the two days of holding your warfarin. Since you have your own Coaguchek and it seems accurate, I see no downside in testing. I know that many are in the testing weekly mindset, apparently even some clinics, but when your INR is going wild, in my view you want to test more frequently, so as to not overcorrect.
During my wild, amiodarone fueled, week, my INR went from 3.1 to 9.7, to 1.6 then to 5.6. The Coumadin Clinic had me down at the lab testing daily. They even had me test twice one day, as we wanted to see which direction things were headed within 4 hours after taking vitamin k.

Holding warfarin for two full days, then dropping to half a dose for several days seems like a very big reaction. It may very well be warranted, but it could result in undershooting your INR. For example, it is entirely possible, even if unlikely, that you could be under 2.0 INR after holding for two days. That would be very good information to know before going on half a daily dose for several more days before retesting.

Ideally, you want a gentle landing into range, rather than a yo yo week of undershooting then possible overshooting again.

I'm not saying not to follow their guidance, that is, of course, what you should do. But, having a bit more spot checking on how quickly your INR is moving won't hurt, in my view.

For what it's worth, during my wild week, when I was at 5.6, they had me hold for one day, then test again the next morning before deciding on whether to hold again or dose. It dropped significantly from the one day hold and they decided to dose me the next day, rather than have me hold for another day. I was soon in range, and you will be too.

It seems like you have had a bit of a wild week, almost certainly caused by the grapefruit. But, 5.6-5.8 is really not that alarming. When I hit 9.7 INR I was very concerned. I asked the clinic if I should check into the ER and get intravenous vitamin K. They said that they don't have patients generally do that until they hit 12 or 13 INR. They gave me a prescription for vitamin K and told me to just be very careful not to fall or hit my head for the next few days. Boxing was clearly off the menu.

So, your INR is a little out of range. But, the good news is that you and the clinic are aware of it and are taking action. You are relatively new to warfarin and it sounds like early fluctuations are normal, especially when adding something, like grapefruit, which interferes with how warfarin acts. Just be sensible and don't do anything likely to cause a bleed in the next few days and you should be back in range soon. Until then, put a hold on the machete juggling and sky diving :)
thanks for that !
I'll take your advice and use my coagucheck meter on Saturday morning to see where I am ! 👍
 

leadville

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Eating times are pretty irrelevant.
The grapefruit is the stand out culprit but do not write off that you are consuming something else too since you got home.
Its frustrating but you will soon get on top of this.
Keep us updated and ask as many questions as you like no doubt you may Have a few .
Good luck
 

pekster11

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only other thing i can think of is at the end of last week and most of this week i have been eating a home made casserole (i made a big pan of it which has lasted 5 days)

In it was onions, carrots, butter beans and cooking chorizo, the sausage variety which is alot stronger than the sliced chorizo they sell to put in sandwiches (which I know contains paprika)

Do you think the chorizo could have also helped increase my INR as it has paprika in it ?
 

pekster11

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i've been reading a bit about genetics and warfarin response.

it seems as though the high response and low metabolism i seem to show for warfarin which means i need a v small dose of it to get my INR in range is far more common amongst East Asians than Europeans.

Maybe somewhere in my ancestry I have Chinese ancestry ?
23andme and ancestryDNA both have me as 100% European though 🤔
 

pellicle

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i've been reading a bit about genetics and warfarin response.
...
Maybe somewhere in my ancestry I have Chinese ancestry ?
its an interesting question but a bit unimportant because in reality all that matters is measuring and dosing accordingly ... its like discussing which wood is being used when you'll still use a tape measure before cutting it.
 

ATHENS1964

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So......

I tested myself this morning with my Coaguchek INRange meter...I got 5.8 !!!! :oops::oops:
I thought there must be something wrong with either the meter, the testing strips or my technique !!

Went to the INR clinic about an hour later and had blood withdrawn from a vein to test INR
Results just back....5.6

Surgery rang me with the results

New dosage for the next week as advised by the surgery...today and tomorrow...no warfarin...after that 1mg per day, until results of next INR test (next week)

I haven't had any grapefruit juice since Saturday btw
What the F is going on !!! :(:confused:
something i miss, i have the opinion that usually roche inrrange has some differences in relation to measurement in lab.
For example, mine is 10-15% different and from what I have read, as the inr goes up, the difference increases. So you who showed 5.8 would estimate that the lab would say 4,3.

I would like to ask Pelice, we have said that the machine is just a computer and the chemical reagent is the strip, why does the laboratory show me 15% and someone else 20% or 5%? something I do not understand .
 

Chuck C

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I would like to ask Pelice,
I'm pretty sure you mean Pellicle. Anyway, might want to correct the typo so that he gets a message that his handle was mentioned and can respond and so that he won't get offended and sick his Foster's drinking boxing kangaroo on you :)
 
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