Hi and welcome
... I’m on acenocoumarol (Acitrom)
really ... in Canada? That's interesting and weird. If you were in (say) the 3rd world, India or Eastern block Europe (stick Spain in there for the time being) I'd expect Acitrom but Canada?
Who prescribed that? I didn't even know it was available there.
This isn't just trivial its actually a core issue. You see, of the three anticoagulants, this has the shortest half life and results in the highest volatility within the patient
Some notes:
Acenocoumarol (sintrom, acitrom ) is an alternative to warfarin it is called
Elimination half-life 8 to 11 hours
Phenprocoumon (germany)
Elimination half-life 6–7 days
Warfarin (most common)
Elimination half-life 1 week (active half-life is 20-60 hours)
[my note: weird notation of "active half life"]
its worth noting that 20 - 60 hour range (so between a day and three days).
This variation in half life has significant effects on how to manage the drug and how it responds to "oops, I forgot my dose"
Basically with Acitrom your INR will be 1 again after 30 hours, with warfarin or Phenprocoumon you've got time to just retake and not fluff things up wildly.
Acitrom is so sensitive to INR changes I've discovered (in working with others) that 12 hours difference in when you measure vs when you take shows a difference in INR. So this means:
- if you take your pill at 7am and test at 9am vs 5pm you'll see INR difference (I've seen 2.7 vs 1.8)
- if you take at 8pm the same sort of problem emerges
To understand this perhaps this helps
Anticoagulants with vitamin K antagonism include the coumarin derivatives acenocoumarol, phenprocoumon, warfarin and the indanediones, fluindione and phenindione. Most VKA are completely absorbed following oral administration and bound to albumin in the plasma by more than 95%.
The elimination half-life is 24 hours for acencoumarol (including its metabolites), 36 hours for warfarin and 150 hours for phenprocoumon.
The half-lives of the clotting factors range between 8–72 hours.
Consequently, it takes several days for the inhibitory effect on the synthesis of the coagulation factors to result in reduced concentrations in the liver. [personal note: I'm sus on the several days and lack of understanding about time to reach steady state] . Coumarin derivatives are metabolized in the liver and excreted by the kidneys. They are particularly susceptible to interactions with other drugs that are able to compete with them for plasma protein binding, alter their metabolism in the liver, or inhibit or stimulate synthesis of the clotting factors.
please observe my [personal notes] .. there's a lot in the above 3 paragraphs and it deserves a question answer all on its own. However it all depends on the amount and depth that you want to understand this in... I'm that guy who dives deep.
and know that INR levels can fluctuate during the first few months.
INR always fluctuates, but its actually well documented that after the first weeks or months you will have a decreased sensitivity to warfarin. This article from 2010 seems not to have yet reached the medical commuinty 14 years later:
Decreasing warfarin sensitivity during the first three months after heart valve surgery: implications for dosing
K Meijer 1,
Y-K Kim,
S Schulman
However, my recent test came back with an INR of 1.5, down from 2.2 last week.
assuming that you are being tested at the same time, and taking at the same time then perhaps its time to simply "increase your dose" as noted above.
My doctor said it’s not a major concern, increased my dosage to 4-4-5, and asked me to test again in 10 days.
as you can see from the above details about half life this strategy of "averaging the doses" is not appropriate with Acitrom
I’ve been eating a variety of foods and haven’t had any alcohol, and I don’t think I’ve consumed any significant amounts of vitamin K.
good ... a healthy balanced diet is fantastic.
Is there something I might be missing?
Hopefully I've filled in what's missing. Feel free to ask anything to clarify anything I've said.
To describe me a bit, I read this recently and thought it applies to my whole life:
Marlinspike brought up Pretty Good Privacy (PGP), a set of encryption tools first shipped in 1991. PGP was many people’s first experience with encrypted messaging—and their last for years after butting heads with its arcane user experience.
“We would teach people how to run a PGP keyserver,” he reminisced, chuckling. “We'll just hang out over dinner and sign keys or whatever.”
Alas, people were willing to do no such thing: “We were just wrong.”
AKA they were idiots*
So short answer summary:
- INR is the only thing that matters, dose as needed for INR nothing more, nothing less
- Do not adjust for food unless that's going to become your whole new normal
- beware of dosing and testing times with Acitrom
PM me if you want to converse
Best Wishes
PS: * idiot defined
Pirsig’s mechanic is, in the original sense of the term, an idiot. Indeed, he exemplifies the truth about idiocy, which is that it is at once an ethical and a cognitive failure. The Greek idios means “private,” and an idiōtēs means a private person, as opposed to a person in their public role—for example, that of motorcycle mechanic.
Pirsig’s mechanic is idiotic because he fails to grasp his public role, which entails, or should, a relation of active concern to others, and to the machine. He is not involved. It is not his problem. Because he is an idiot.
This still comes across in the related English words “idiomatic” and “idiosyncratic,” which similarly suggest self-enclosure. For example, when a foreigner asks him for directions, the idiot will reply idiomatically, rather than refer to a shared coordinate system. He also lacks the attentive openness that seeks things out in the shared world, as when Pirsig’s mechanic “barely listened to the piston slap before saying, ‘Oh yeah. Tappets.’”
At bottom, the idiot is a solipsist
