INR sensititity to leafy greens

Hello everyone, great site, I have been following since after my second OHS four weeks ago and there is some great people here both in terms of knowledge and in terms of support.
Just a quick background, I am a former aortic bicuspid valver, I had a valve sparing procedure in 2008 that didn’t work very well ( after 6 months I had again 2+ regurgitation and then became stenotic after only 5 years, first moderate for a few years and then severe the last few years. Somehow my heart hanged in there with severe regurgitation and severe stenosis for the last few years and since it was contracting well and I was able to exercise and didn’t have real symptoms (other than PVCs) they had me waiting as long as possible but planning to fix it before there was permanent damage to the heart. I was being monitored every 6 and sometimes every 3 months.Four weeks ago I got on On-x aortic valve.

I am doing pretty well I think but I am one of those that is still anxious about the warfarin and hope I will get used to it. I am in my first month so we are still finding the right dose, my target for now is INR 2 to 3. At 5 mg of warfarin my INR was 1.9, then at 6 mg it went up to 2.2, 2.5 one week later and today (another week later) is 2.7. I have been eating zero greens, but I’ve been eating other vegetables (tomato, mushroom, onion, potato’s…). It seems like without greens 6 mg would be the right those. Here is my question, based on your experience, and of course everyone is different, if I start eating a medium salad ( just lettuce, asparagus, avocado) every day ( no spinach or kale) what effect would you think it would have on the INR? It may sound like a weird question but I am worried about eating a salad and my INR getting too low (lower than 2). In a few days I get my coaguchek and I will do some testing but I thought I would ask how much of an impact it has for other members so that I feel safer in my tests. I am from Europe (living in the USA) now and for us a medium salad is probably a small salad in US standards.).

Thanks a lot for any feedback you can provide and if anyone has a successful protocol to check INR sensitivities to greens in a safe way please share. Thanks again!

Hi and welcome

Windfinder said:

I am doing pretty well I think

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excellent

Windfinder said:

but I am one of those that is still anxious about the warfarin and hope I will get used to it.

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I find the best way to "get used to it" is to engage with it and understand the basics of how it works. Its about as complicated as a petrol engine (that may put you off, but I'm a petrol head).

Windfinder said:

I am in my first month so we are still finding the right dose, my target for now is INR 2 to 3. At 5 mg of warfarin my INR was 1.9, then at 6 mg it went up to 2.2, 2.5 one week later and today (another week later) is 2.7.

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seems like a reasonable steady progression

Windfinder said:

I have been eating zero greens

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well, perhaps don't and perhaps just eat what you'd normally eat ... its not sustainable to take on a new (and unhealthy) regime.

Windfinder said:

but I’ve been eating other vegetables (tomato, mushroom, onion, potato’s…). It seems like without greens 6 mg would be the right those.

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it probably makes less difference than you think, unless you're eatng 300g of Brussles sprouts (waves and smiles) per day.

Windfinder said:

Here is my question, based on your experience, and of course everyone is different, if I start eating a medium salad ( just lettuce, asparagus, avocado) every day ( no spinach or kale) what effect would you think it would have on the INR?

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nothing measurable

Windfinder said:

It may sound like a weird question but I am worried about eating a salad and my INR getting too low (lower than 2).

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that could have been a coincidence ...

Windfinder said:

In a few days I get my coaguchek and I will do some testing

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(cheers \o/) that's great news

Windfinder said:

Thanks a lot for any feedback you can provide and if anyone has a successful protocol to check INR sensitivities to greens in a safe way please share.

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reach out and I can help set you up on a good path ... you may or may not stick with what I can put before you, but if nothing else its excellent training wheels.

Best Wishes

Welcome to the Forum. You will never find a "forever dose". Eat your salads and adjust your Warfarin to stay inside.....or close to your range of 2-3. I have talked many times over the years with patients and professionals as to why INR varies.......even tho my eating habits don't change very much. The professionals and INR veterans will tell you........"it just happens and don't worry about it" and adjust your dose to maintain your range. That's why the doctors give us a one-point INR range. My range is 2.5-3.5 and my personal target is a little over 3 and any sequence of INR readings around that target is OK with me. I only change my dose if my INR shows a trending away from my range.

Thanks a lot mate! I will reach out to you when I get the machine!

Windfinder said:

Thanks a lot mate! I will reach out to you when I get the machine!

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nothing wrong with tracking your data as things go along ... you don't need to be the mechanic to benefit by observing what's going on.

Best Wishes

I've never noticed that any food affects my INR much and I eat lots of vegetables of all kinds. I don't eat kale because I think it tastes like dried leaves, but I do eat plenty of spinach. The one thing that does affect my INR is alcohol. I typically average fewer than 1 drink a week, but if I go on vacation where I have a drink or two every day, my INR will go up, even though I'm much more active than normal. I always joke that I drink Bloody Marys to balance the alcohol! Even so, I don't worry about it and I get back in range once I'm home.

Hello Windfinder...
Welcome to this great forum.
I've been navigating INR management for the first time myself of late, with the help of some lovely people and posts here.

I think I'm finally settling into a steady understanding and method of management. I've now been in range for some weeks.

I don't have a mechanical valve but a five-year-old Inspiris Resilia bioprosthetic implant. I am now on permanent warfarin due to cardioembolic (mini) stroke last December.

Wishing you a continuing good recovery from your surgery and all the best with your INR learning curve.

*Any (further) questions, ask away.

pellicle said:

... unless you're eatng 300g of Brussles sprouts (waves and smiles) per day.

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... Wave acknowledged.

One thing that used to be written about - and still applies now - is to have a consistent diet - as consistent as possible. If this means eating two pounds of salad a day (who eats that much salad?), eat two pounds of salad EVERY day. Once you've adjusted your dosing to your diet, your dosage shouldn't change much.

Certain inconsistencies shouldn't change things very much -- for example, I may eat a salad for two or three days, then skip it for a week or more - I don't worry much about possible minor changes in my INR. My dosing is still the same, and any minor fluctuations in INR as a result of 'inconsistent' events isn't very consequential.

So - to wrap it up - if you want to eat a lot of leafy greens - go for it. Just set your set your dose to bring your INR in range, test weekly, and don't worry about the effect of the greens.

Hi Windfinder,

After 12 years on 52.5 milligrams of Warfarin per week, eating a consistent diet with few greens (maybe one salad per week), and being within my INR range of 2.5 to 3.5 about 95% of the time, I decided to become a vegan six months ago. I did this cold turkey and fully expected it to play havoc with my INR, which of course it did, as well as ruining my consistent INR record. However, I had begun testing more often so that I could make quick adjustments to my dosage, sometimes over compensating and sometimes under compensating. It took me a couple of months to arrive at a new permanent dosage level of 60 milligrams per week and my INR is again stable. I did not involve my primary care doctor or cardiologist because I did not need or want anyone else's opinion about what I was doing. By the way, in the six months since going vegan my total cholesterol has dropped almost 100 points down to 156 and my LDL and triglycerides have also dropped substantially.

QuincyRunner said:

Hi Windfinder,

After 12 years on 52.5 milligrams of Warfarin per week, eating a consistent diet with few greens (maybe one salad per week), and being within my INR range of 2.5 to 3.5 about 95% of the time, I decided to become a vegan six months ago. I did this cold turkey and fully expected it to play havoc with my INR, which of course it did, as well as ruining my consistent INR record. However, I had begun testing more often so that I could make quick adjustments to my dosage, sometimes over compensating and sometimes under compensating. It took me a couple of months to arrive at a new permanent dosage level of 60 milligrams per week and my INR is again stable. I did not involve my primary care doctor or cardiologist because I did not need or want anyone else's opinion about what I was doing. By the way, in the six months since going vegan my total cholesterol has dropped almost 100 points down to 156 and my LDL and triglycerides have also dropped substantially.

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This is a perfect example of what we mean by 'dosing the diet' and not 'dieting the dose'.

Best to eat what we want, and include a lot of greens, which are very important to good health, and dose warfarin accordingly.

QuincyRunner said:

Hi Windfinder,

After 12 years on 52.5 milligrams of Warfarin per week, eating a consistent diet with few greens (maybe one salad per week), and being within my INR range of 2.5 to 3.5 about 95% of the time, I decided to become a vegan six months ago. I did this cold turkey and fully expected it to play havoc with my INR, which of course it did, as well as ruining my consistent INR record. However, I had begun testing more often so that I could make quick adjustments to my dosage, sometimes over compensating and sometimes under compensating. It took me a couple of months to arrive at a new permanent dosage level of 60 milligrams per week and my INR is again stable. I did not involve my primary care doctor or cardiologist because I did not need or want anyone else's opinion about what I was doing. By the way, in the six months since going vegan my total cholesterol has dropped almost 100 points down to 156 and my LDL and triglycerides have also dropped substantially.

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That's kind of interesting. Are you eating a lot more soy/tofu than you did before? People always think about leafy greens and vegetables when they think about Vitamin K, but even though spinach has a lot of Vitamin K, it's measured per 100 g, and that's over 3 cups, so most people don't eat that much in one sitting. Mayonnaise, cheese, milk, chicken, turkey, bacon, and other non-vegetables also have high amounts of K, and 100 g of chicken is only about 4 oz, or 100 g of soft cheese is less than half a cup, either a rather small amount for most people to eat in 1 meal, so often when someone changes to a vegan or vegetarian diet, their Vitamin K intake isn't as significantly different as expected.

Such a great responses, so informative and it’s making me a lot more relaxed about ACT. thank you everyone. I will post the results of my tests just for those who are curious or that may want to compare or see how different we may react to changes. Thanks again!

Windfinder:

What you described (sometimes too high, sometimes too low) looks like what some of us call the 'roller coaster effect.' This happens when your dosage adjustments are too large - for example, adding or subtracting a mg or two. Clinics sometimes (often?) do this and don't understand why the INR suddenly appears out of range.

In my experience, small steps are best - my INR sometimes fluctuates (and this happens to all of us), and my changes are usually .5 mg at a time. Retesting after 3 days should give you a good picture of where your INR is after the change.

I've been self managing for 15 years, but Pellicle is the Yoda of anticoagulation.

Protimenow said:

Windfinder:

What you described (sometimes too high, sometimes too low) looks like what some of us call the 'roller coaster effect.' This happens when your dosage adjustments are too large - for example, adding or subtracting a mg or two. Clinics sometimes (often?) do this and don't understand why the INR suddenly appears out of range.

In my experience, small steps are best - my INR sometimes fluctuates (and this happens to all of us), and my changes are usually .5 mg at a time. Retesting after 3 days should give you a good picture of where your INR is after the change.

I've been self managing for 15 years, but Pellicle is the Yoda of anticoagulation.

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Thanks Protime! Yes, I’m learning from all of you and I have Pellicle’s contact for extra support !

I have a couple years with the On-X since June ‘22. I had a couple dips with INR down to 1.9 but generally in that 2-3.5 range. I was a little concerned about spinach but really have not seen food impact my INR. I have not yet tried grapefruit - that may have the biggest impact. Think I have seen that caution on this site.
There is another thing to be aware of - antibiotics. They’ve thrown my INR off for a couple days. I get some recurring UTI that sometimes requires antibiotics. It’s a minor hiccup on the overall trajectory of stable INR and seems like my system just does an auto compensation, but it can be unnerving.
I have been fortunate to not adjust my warfarin dosing except during antibiotics. It’s been 7.5 mg except for 10 mg on Tuesday which seems utterly random but I am willing to comply.
Not clear on the details the way Yoda/pellicle knows, but INR readings seem to take 3 days to really reset. So does one meal make a difference? I don’t think so, but I don’t know.

treichert0312 said:

I have not yet tried grapefruit - that may have the biggest impact. Think I have seen that caution on this site

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https://www.valvereplacement.org/threads/fruits.889572/#post-933057

https://www.valvereplacement.org/threads/foods-on-warfarin.888552/#post-916261
just to add to those things, I don't think having (say) a half grapefruit as a side on breakfast will be a bad thing (except the taste, and my view is if it needs sugar or tomato sauce to cover up the taste then its not worth eating). The problem mainly comes from drinking the (always sweetened) juice.

https://www.valvereplacement.org/threads/my-monty-python-moment.42094/#post-767998

However if you're going to be doing it every day; then if you aren't already measuring your INR weekly then do so from starting eating grapefruit.