Up and down INR!?

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Amy

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so your GP can't?
More like won’t. Apparently it’s a liability issue, and since most PCPs/GPS have no idea about warfarin (yet resist being told they don’t need to do anything - that they can just give you the prescription - since one self-manages) they often refuse, referring you to the ‘Coumadin clinic’ or advising you to get it from your cardiologist. A double bind.

Someone needs to make a ‘warfarin test’: if you can answer 30 questions about warfarin adjustments, interactions, missed doses, INR - you get to skip the runaround. : ) Right?
 

Chuck C

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More like won’t. Apparently it’s a liability issue, and since most PCPs/GPS have no idea about warfarin
I think Pellicle needs to start a black market for warfarin. He can be our very own warfarin peddler 🤣
I have more confidence in him regarding dosing anyway.
 
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Mister_James

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So here is the deal. If you are on 5mg, you can tell your physician that you take 7.5mg or do the song and dance, If necessary, report lower INR and say you have upped your greens and be placed on higher dose.
Your doctor will write a refill at your new dose.
I am on a 7.5/7.5/5 schedule. My doctor writes a straight 7.5mg. After 5 years, I have probably 90 days supply of warfarin built up.
 

Keithl

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so your GP can't?
A lot of GPS will defer to cardio. Almost every cardio will want a service and claim legal and policy issues. My GP I have been seeing for over 12 years and she knows me well and agreed to prescribe for me since I showed her my records and my spreadsheet that has every reading since I started over 2 years ago.
 

Dana

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EMJEF -- if you're taking 9 mg one day and 10 mg the next, your INR will vary slightly depending on the day that you test it. The swing will be a result of the varying dose coursing through your system.

Taking the same daily dose should make your INR reading more consistent, day to day.

The easiest way to do this is to get 7.5 mg of Warfarin, then add 2 mg (you can do this with two 1 mg pills, 1/2 of a 4 mg pill or, if available, one 2 mg pill).
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Grapefruit, and grapefruit juice interacts with many medications - and not just warfarin. Personally, I stay away from it - even in its dilute form.

Cranberry, and cranberry juice (and cranberry juice cocktail, cran-orange, cran-raspberry, cran-whatever) can also cause changes in your INR - especially if you have a lot of it.

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K2 has no impact on INR. You may want to check your bottles of K2 to be sure that they don't contain K2 AND K1. Sometimes they will.

I've been taking K2 plus D3 (in a single gel cap), or K2 by itself plus D3 capsules. The pure K2 hasn't had any effect on my INR.

It's K1 that can cause problems -- NOT K2

FWIW - Before I started to self-test, I had a blood draw, and my doctor called me, frantic, because my INR was 7. I just reduced my dosage and was careful not to injure myself for a few days.
 

Dana

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EMJEF -- if you're taking 9 mg one day and 10 mg the next, your INR will vary slightly depending on the day that you test it. The swing will be a result of the varying dose coursing through your system.

Taking the same daily dose should make your INR reading more consistent, day to day.

The easiest way to do this is to get 7.5 mg of Warfarin, then add 2 mg (you can do this with two 1 mg pills, 1/2 of a 4 mg pill or, if available, one 2 mg pill).
---

Grapefruit, and grapefruit juice interacts with many medications - and not just warfarin. Personally, I stay away from it - even in its dilute form.

Cranberry, and cranberry juice (and cranberry juice cocktail, cran-orange, cran-raspberry, cran-whatever) can also cause changes in your INR - especially if you have a lot of it.

---

K2 has no impact on INR. You may want to check your bottles of K2 to be sure that they don't contain K2 AND K1. Sometimes they will.

I've been taking K2 plus D3 (in a single gel cap), or K2 by itself plus D3 capsules. The pure K2 hasn't had any effect on my INR.

It's K1 that can cause problems -- NOT K2

FWIW - Before I started to self-test, I had a blood draw, and my doctor called me, frantic, because my INR was 7. I just reduced my dosage and was careful not to injure myself for a few days.
I have found that vitamin K2 MK-4 has no impact on INR as you said, but vitamin K2 MK-7 has the same effect as vitamin K1 and possibly more. If you are taking K2 as a supplement from a bottle, check the label to see if it's MK-4 or MK-7. Likely if it's not affecting your INR, it's MK-4. Whenever I need to make a downward correction correction in INR I will take between 0.5 and 1.5 teaspoons of natto, which if you don't know is fermented soybeans popular in Japan and it is one of the richest sources of vitamin K2 known with an exceptional concentration of K2 MK-7. (MK-4 may actually have coagulation properties but its bioavailability is so poor that it doesn't produce any detectable levels in the blood (see note 1) when taken at nutritional levels compared to what MK-7 does.) As a relative comparison, cooked kale contains about 882 micrograms per cup (a lot); kale is one of the highest of the green leafy veggies in terms of vitamin K content. Natto has the K1-equivalent of about 115 micrograms in a teaspoon (see note 2). There are 48 tsp/cup!
I'm confident enough with that estimate that I use a measured amount of natto as a quick fix for a vitamin K daily shortage in my diet.
Natto is hard to find commercially in quantity. Natto can be fermented at home, as I've done in the past. There are recipes online.

Note 1. Comparison of menaquinone-4 and menaquinone-7 bioavailability in healthy women
Note 2. the 115 mcg is an equivalency number that I used based on my own trials. Natto does not have much K1 and if you look for nutritional information on natto, you will likely find its vitamin K1 content which not exceptionally high. However the MK-7 content does have coagulation properties at a rate that I've determined to be equivalent to 115 mcg of K1. Now there are a lot of conflicting sources on the internet. One says "A single tablespoon of natto contains more than 150 micrograms of Vitamin K2 as MK-7..." So a tablespoon is three teaspoons. Another source says natto contains about 40 mcg of vitamin K per cup. Go figure. I'm reporting what I have empirically found as measured by its affect on my INR compared to an equivalent amount of vitamin K1.
 

Dana

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When I learned that my mitral valve was likely calcified I started routinely consuming natto because vitamin K2 has been associated with a reduction in valvular calcification so natto was recommended to me by a friend. For a year or so prior to my OHS for three valves (two of them mechanical) I was taking it.
My surgeon definitely confirmed significant amount of valvular calcification (exacerbated by prior radiation treatments he says). So warfarin and its limitation on vitamin K consumption was a problem for me because it denied me the very nutrient probably needed to minimize further calcification!. Now I use natto very sparingly because of its K2 MK-7 content and its effect on INR.
 

Dana

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Thanks. Good paper. First time I've ever seen quantitative information on K2 MK-7 effects on INR and it shows it to be more potent than K1 as I've found empirically. It will be interesting to do the math comparing these numbers with my own findings.
 

pellicle

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So warfarin and its limitation on vitamin K consumption was a problem for me because it denied me the very nutrient probably
I believe you can have sufficient vitamin K2 as @ATHENS1964 suggests. Just keep an eye on your INR via your weekly testing. I don't anticipate you'll see much movement. Just adjust the warfarin dose as required to remain in range
 

Humboldtgrrl

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@ATHENS1964 @Dana Thanks for above cite. Here is another one I've collected re osteo but now have known AV calcification, so will wait til my latest DEXA results (now that I'm on a pricey multi with K2M7). If still problems, will try the Natto again (it's an acquired taste IMHO), as it seems to have a bigger effect on the calcification as well as osteoblasts. I also just got put on Eliquis for some pulmonary emboli, but this paper indicated Eliquis is not K dependent. Research is always an ongoing evolution. https://www.tandfonline.com/doi/abs/10.1080/10408398.2016.1211616?journalCode=bfsn20
 

Pennysendsu

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This is off topic maybe, but what website do you guy's go to for vitamin K amounts in food? I use to go to INRTracker.com. It's not there anymore and so I tried researching on Google and got nowhere. Is there another website any of you use?
 

Chuck C

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This is off topic maybe, but what website do you guy's go to for vitamin K amounts in food? I use to go to INRTracker.com. It's not there anymore and so I tried researching on Google and got nowhere. Is there another website any of you use?
I hope that no one on your medical team told you that you need to carefully track how much vitamin K that you are ingesting daily to make sure that you eat the same amount every day. My personal experience is that the small amount of vitamin K in foods does not seem to move my INR at all and some days I eat two big salads. Some days I have one or none. I think most others on warfarin have shared the same experience.
 

pellicle

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This is off topic maybe, but what website do you guy's go to for vitamin K amounts in food? I use to go to INRTracker.com. It's not there anymore and so I tried researching on Google and got nowhere. Is there another website any of you use?
None, it doesn't matter. Eat and don't obsess over what is a trivial nonsense.


No matter what you need to eat a healthy diet. Perhaps the worst people you can discuss this with or place any trust in is Dieticians. Clinicians are not medical specialists and seldom know more than is absolutely needed to do thier job. So whoever mentioned to you that you need to track you vitamin K intake was misguided and based on like 30 year old (unsubstantiated) myths.

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