Warfarin is very tweaky

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djman

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I am 1 month post surgery. On Amiodarone which reduces Warfarin dose, plus other things which don't matter.

Warfarin 2mg per day -> INR 3.2
Drop to 1.5 mg per day and test 4 days later -> INR 1.8

So until the next test my dose is to alternate 2mg followed by 1.5mg. Gonna see how this goes. And fwiw, I have 1mg pills. I cut them in half as needed. I don't think Canada has 0.5mg pills available.
 

pellicle

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Hi
not sure that anywhere has 0.5mg pills. I break the 1mg pill in half (as you are doing). The argument that you'll get 0.485mg in one dose is countered by the fact that you'll get 0.51mg in the next (with some loss to crumbs) ... :)

Given your very small dose management of that dose is going to require you do that.

INR 3.2 shows you're managing INR well (or your team is)

(As you may know) Amiodarone has a very long half life and inhibits your bodies ability to dispose of warfarin (cytochrome P450), so don't be surprised when you come off that your dose goes back to something over 5mg (predicting 7mg but then I do love a bet).

Best Wishes
 

pekster11

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you seem to have similar warfarin dosing to me (varying between 1.5-2mg/day to keep in range)

believe me, over the course of a week taking 1.5mg/day compared with 2mg/day will make a big difference

as a percentage, that's a significant change

as Pellicle said splitting the 1mg pills into ~0.5mg pills is easily done with a pill-splitter
 

tom in MO

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The months immediately after surgery my INR was more variable. My nurse told me it was common..
 

djman

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Thanks for the responses. Just had another test on the alternating dose. INR 2.3 which is great.

Oh and I would take the other side of pellicle's bet. Based on data from my pre surgery Warfarin trial, I expect 4mg without Amiodarone. (I was fortunate to have that trial).
 

Chuck C

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done (even though you've had a peek at the answer) ... so, stakes are a pint of Guinness
Drinking a pint of beer? Haven't you heard certain members of the medical community? As you are on warfarin, that's like drinking cyanide! Dibs on the motorcycle.
 

Chuck C

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Thanks for the responses. Just had another test on the alternating dose. INR 2.3 which is great.
That's great news!
Based on data from my pre surgery Warfarin trial, I expect 4mg without Amiodarone. (I was fortunate to have that trial).
It is remarkable how much amiodarone impacts INR. Without amiodaron it took 4mg of warfarin to stay in range. Now on warfarin, your dose had to be reduced to 1.75mg/day. That's a 56% reduction!

You may have read my story in which I was put on oral amiodarone upon release from hospital and my INR shot from 3.1 to 9.7 in 3 or 4 days. Like you, I had to reduce my dosage by about 50% to get back in range. Yes, 9.7. I was prescribed vitamin k immediately which led to undershooting my range, down to 1.6, and then another overshoot to over 5.0 before settling down into range after a few days.
 

Chuck C

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Feasibility study of the Fearon Algorithm in anticoagulation service guided warfarin management
What I find striking about that trial is the following:

" Median corrected individual TTR increased significantly from 53% (IQR: 39%, 64%) during the year prior to enrollment to 63% (IQR: 57%, 73%) during the AMS phase "

So, the algorithm did improve TTR - time in theraputic range. Being in range 63% of the time is better than being in range 53% of the time. However, both figures should be unacceptable in my view and I hope that all are aiming to have much better TTR than this.
 

pellicle

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However, both figures should be unacceptable in my view and I hope that all are aiming to have much better TTR than this.
agreed ... but clinics don't seem to be interested because they are an unseeing unhuman machine not a collective of people. So its literally dealing with a machine which can't actually ever see you or directly hear you.


from that:

I just found (March 2018) that a quote from a book I read many years ago may have indeed spawned this theory:
“A government is a living organism. Like every living thing its prime characteristic is a blind, unreasoned instinct to survive. You hit it, it will fight back.”
– Ben Caxton (Robert A. Heinlein, Stranger in a Strange Land)
 

pellicle

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Feasibility study of the Fearon Algorithm in anticoagulation service guided warfarin management
amusingly I've tried to get Roche interested in my algorithm on more than one occasion, which gives at least 90% TTR ... but to no avail. The few members here I've set up with it are reporting those ranges. My own TTR (using it) gives me usually 95%

Further I've found other articles (dating from the mid 80's documenting methods for getting patients in range before leaving hospital in 4 doses ... strange that is ignored by "the machine" of Clinic Operation. I remember 10 years ago them telling me to not trust a coaguchek test too ... yet now seem to be doing that themselves.

I submit they are not interested in you only what they perceive (usually stuff like their KPI's and what they see as food: remuneration levels).
 
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Timmay

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@Chuck C , @pellicle :
May I ask what your weekly diets look like in terms of those foods with impactful VitK amounts? (broccoli, spinach, asparagus, salads, etc)? I've been pouring through posts but can't find a short version of what you two (pellicle and chuck) are doing right now in terms of your weekly diet in relation to those specific items. Yes, dose the diet (not diet the dose). I was hoping to keep eating a couple salads a week, broccoli and asparagus once a week, spinach on my turkey tacos once a week. But maybe I am being too hopeful?
 

carolinemc

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If you eat gre
@Chuck C , @pellicle :
May I ask what your weekly diets look like in terms of those foods with impactful VitK amounts? (broccoli, spinach, asparagus, salads, etc)? I've been pouring through posts but can't find a short version of what you two (pellicle and chuck) are doing right now in terms of your weekly diet in relation to those specific items. Yes, dose the diet (not diet the dose). I was hoping to keep eating a couple salads a week, broccoli and asparagus once a week, spinach on my turkey tacos once a week. But maybe I am being too hopeful?
If you eat greens consistent, you do not need to change your green habits.
 

Superman

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@Chuck C , @pellicle :
May I ask what your weekly diets look like in terms of those foods with impactful VitK amounts? (broccoli, spinach, asparagus, salads, etc)? I've been pouring through posts but can't find a short version of what you two (pellicle and chuck) are doing right now in terms of your weekly diet in relation to those specific items. Yes, dose the diet (not diet the dose). I was hoping to keep eating a couple salads a week, broccoli and asparagus once a week, spinach on my turkey tacos once a week. But maybe I am being too hopeful?
Personally, I follow a see-food diet. I see food, I eat it. I never give any thoughts to INR impact. I test weekly or every other week and adjust my dose if needed. If spinach is on the menu, I’ll have that. We have a recipe for a spinach, mushroom alfredo that’s awesome.

Perspective is important though. After close to 32 years on Warfarin, there are probably things I do or don’t do that I don’t even think about anymore. I know I’ve taken an extra milligram after a big spinach day without testing or consulting with my doctor. I test on the normal schedule, I’m in range, and I never mention the extra pill I took.
 
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Superman

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agreed ... but clinics don't seem to be interested because they are an unseeing unhuman machine not a collective of people. So its literally dealing with a machine which can't actually ever see you or directly hear you.


from that:

I just found (March 2018) that a quote from a book I read many years ago may have indeed spawned this theory:
Great book. Heinlein and Philip K Dick we’re both great sci-fi authors from that era.
 

KLS39

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@Chuck C , @pellicle :
May I ask what your weekly diets look like in terms of those foods with impactful VitK amounts? (broccoli, spinach, asparagus, salads, etc)? I've been pouring through posts but can't find a short version of what you two (pellicle and chuck) are doing right now in terms of your weekly diet in relation to those specific items. Yes, dose the diet (not diet the dose). I was hoping to keep eating a couple salads a week, broccoli and asparagus once a week, spinach on my turkey tacos once a week. But maybe I am being too hopeful?
You are not being too hopeful. I eat greens every day. I'll have a salad with romaine or arugula. I put spinach in my protein shake and I'll eat broccoli, asparagus or brussell sprouts once a week or at least every other week. I just try my best to be consistent in the vitamin K I eat each day. If I feel I'm a little low in my intake one day I'll snack on grapes or a kiwi. I'm currently taking 8mg of warfarin a day but left the hospital last year on 2mg or 4 mg a day.
Good luck!!
 

pellicle

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are doing right now in
It hasn't changed much. You seem to be looking for the hidden catch. I'm not writing an insurance company contract.

I eat what I want and pretty much eat anything i want (as superman has reported) I mentioned last night I had some light beers a glass of wine and a brandy with some dark chocolate after dinner.

Dinner (my good mate visited) was fillet steak, green beans, sweet potato, carrots and beetroot.

Lunch had been oriental noodles with pork gyoza stirred with spinach, eschalots and garlic.

Ok not joking when I say in my blog that this diet stuff is over states and over done by (what I can only describe as) twits without any experience.

Sure, some people here obsess and weigh everything, frankly I have better things to do with my time.

If you know how to read a graph (its not just a picture) to understand the data presented in it I'll post my last few years of one testing. Much of it is on my blog and really each years data looks like the previous.

Have you read my blog? This link is everything INR. There is a lot of data there.
 
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pellicle

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Oh, @Timmay

some additional reading which supports my views and my personal experience (as well as the experience of many here)


In conclusion, the available evidence does not support current advice to modify dietary habits when starting therapy with VKAs. Restriction of dietary vitamin K intake does not seem to be a valid strategy to improve anticoagulation quality with VKAs. It would be, perhaps, more relevant to maintain stable dietary habit, thus avoiding wide changes in the intake of vitamin K. Based on this, until controlled prospective studies provide firm evidence that dietary vitamin K intake interferes with anticoagulation by VKAs, the putative interaction between food and VKAs should be eliminated from international guidelines.​

the bold is mine ...

As you may know, I'm reasonably detail oriented and always do my best to chase down the leads as I see them. I do care about my personal health and I have found that worrying about foods (other than the known problems like grapefruit, mentioned twice on my blog) is pointless and just test and know thyself.

If you reach out we can work together (but you will need to commit to weekly measurements and open and honest communication) and you can build a picture over time of the management of INR for you.

Best Wishes
 

Chuck C

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@Chuck C , @pellicle :
May I ask what your weekly diets look like in terms of those foods with impactful VitK amounts? (broccoli, spinach, asparagus, salads, etc)?
I eat tons of foods rich in vitamin K. Foods rich in vitamin K are amongst the very healthiest that we can eat- such as leafy greens. All should strive to eat a heart healthy diet, perhaps those who have had valve issues, even more important. As such, I try to eat as healthy as I can, and that means lots of leafy greens and other vegetables.

Typical day.

Most days I do time restricted eating, so my first meal is often around 12pm. I typically eat a very large Mediterranean salad which would look something like this:
about 100 grams of leafy greens, including spinach. kale and chard.
About 75 grams of shredded broccoli,
chopped bell peppers, red, yellow and orange.
sundried tomatoes
whole olives
chopped onions
1 tbsp of chia seeds
about half an avocado
black beans
a little cheese, typically Romano, parmesan or cheddar
a low carb dressing made with extra virgin olive oil.
I will often add about 4 oz of wild caught sockeye salmon.

For dinner, I will usually eat another serving of my salad, or eat what my wife makes, which is often a salad or, like last night, something like a tofu scramble loaded with vegetables.

So, you can see I eat a lot of greens and other vegetables high in vitamin k. I see no reason to limit my intake at all, and many reasons to eat a diet rich in these vegetables. I'm in INR range well over 90% of the time.
 
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