1.1?!!!!

[Protimenow]

I've been writing as a strong advocate of home testing. I believe in it. I've also looked at self management of dosing and am also a strong advocate.

Until this Monday, I was testing weekly -- I had enough strips that I could afford to test this frequently. With my strip supply starting to dwindle, I thought it would be safe to go to once every two weeks.

My past tests have all be in range - actually, chasing the high end of the range. My last test, on the 18th, was a 3.1.

Something told me that I should go to a test every ten days, so I tested today. During the last week, I haven't had as many meals, and I've had Romaine lettuce and tomato sandwiches with my wife (one of perhaps two daily meals).

Today - ten days after my last test - I was quite surprised to get a value of 1.1. I couldn't believe it, so I repeated the test -- still 1.1. I contacted Alere to see what happens if the strips get too hot -- I was told that if they get too hot, I'd be getting QC or other error messages, but no results.

I tried with a newer lot of strips -- and got a 1.3. Apparently my INR took a nosedive during the last 10 days. Now, I'm sorry I didn't test on Monday - one week after the previous test. If my INR was dropping then, I could have made some minor adjustments. (For those of you with doctors who say that two or three weeks between tests is okay, let my story be a good reference.)

So -- I'm faced with some decisions. I can't afford Lovenox and don't know if I'd take it even if I had a doctor and medical insurance. I don't think I missed a dose of warfarin - but this could help explain the 1.1.

I usually take 49 mg/week (7 a day), and I know I took my 7 mg last night. I also know that, even at 1.1, I don't want to make any dramatic changes to my dosing. I just took 5 mg (getting the eventual climb 12 hours before I usually take my warfarin shouldn't hurt), and I'll take 3 mg tonight at bedtime. I'll probably do the same tomorrow. I'll drop back to 7 on Sunday, and test on Monday. If the INR is back up, I'll assume that either I missed a dose on Monday or Tuesday, or my new diet had something to do with it, or both.

I'm not sure about curtailing activities (I'm supposed to help out at a Barbeque tonight) because of this lower INR, but I think about Dick's problem when he missed some doses.

Any thoughts from the experts out there?

Thanks

 

[dick0236]

It is unusual to drop from 3.1 to 1.1 in ten days on one missed dose and I would question that one, or two, Romain lettuce sandwiches would cause that kind of INR drop. My INR chart says to increase weekly dose by 20% for INR >2.0. That would be about 10mg/wk in your case. Taking 8mg/day for a few days may help to get your INR up to your range. Test again on Tuesday and go from there. If it was a blip, and they can occur, the additional dosing may take you to the hi side, and if it was a accurate number, the additional 7mg/wk should bring it back up.....but remember, I am not a doctor and that is what I would do.....with the approval of my PCP.

I know that you purchase your strips "on-line" and I personally would be very uncomfortable of what I was getting via many internet sources, unless I was certain that they are subject to US FDA control. There are more and more reports of bogus medical products being sold on line......and like they say, "let the buyer beware".

 

[Protimenow]

I am using an InRatio machine. I think it's a supplement that I just started taking that had an effect on my INR.

As far as being wary of the strips -- I'm not worried -- although I changed to a new batch of strips last month, the results were consistent with those from my previous lot. I re-ran the test using a batch I got from an online dealer, and verified the number by testing with a strip that I got directly from the manufacturer. The strips that I use are all factory sealed, appear to be genuine. All future strips will have the Alere logo and Alere colors on them. I'll be using strips I got directly from the manufacturer for some time to come. I'm not sure about bogus InRatio strips being reported.

I haven't consulted an INR chart for a while -- I'll do as planned (for now) and take 8 mg for the next two days - then test on Monday and see if things are trending back to normal.

Thanks for your input.

 

[Lynlw]

It is unusual to drop from 3.1 to 1.1 in ten days on one missed dose and I would question that one, or two, Romain lettuce sandwiches would cause that kind of INR drop. My INR chart says to increase weekly dose by 20% for INR >2.0. That would be about 10mg/wk in your case. Taking 8mg/day for a few days may help to get your INR up to your range. Test again on Tuesday and go from there. If it was a blip, and they can occur, the additional dosing may take you to the hi side, and if it was a accurate number, the additional 7mg/wk should bring it back up.....but remember, I am not a doctor and that is what I would do.....with the approval of my PCP.

I know that you purchase your strips "on-line" and I personally would be very uncomfortable of what I was getting via many internet sources, unless I was certain that they are subject to US FDA control. There are more and more reports of bogus medical products being sold on line......and like they say, "let the buyer beware".

Along the same lines, I would wonder about the Coumadin and if that is fake, since I think you'd have to miss quite a few days to end up at 1.1.

 

[Protimenow]

No. I've been taking this same batch of warfarin for MONTHS, and I've got my dose and INR working together. I don't think they'd thrown in a bad batch of pills among all the other good ones.

I think there's a supplement - containing seaweed - that I just started taking that must have had a lot of Vitamin K in it that caused the rapid drop.

I have no doubts about the strips or the warfarin.

Thanks for your input.

 

[Protimenow]

I started this thread because I wasn't sure what caused my rapid drop in INR, and didn't know if I should make any changes to activities because my INR was so low. I don't mistrust either my warfarin (or the source) or the meter. I wasn't sure about the strips because they were exposed to a few 90+ degree days. I'll be getting some new strips on Monday or Tuesday and will check then -- but I suspect that my increased dosage will bring me near range.

I strongly suspect that the medication I just started - and upped the dosage on -- probably caused the steep drop. Once I'm back in range, I'll try the medication again, but monitor is closely to make sure that my INR, with the med in my system, stays in range.

(I'm still not sure about activity/inactivity with this low INR, but will do what I have to do and just hold my breath, hoping that there are no clots in my future)

Thanks Dick and Lyn, for your comments.

 

[Lynlw]

I started this thread because I wasn't sure what caused my rapid drop in INR, and didn't know if I should make any changes to activities because my INR was so low. I don't mistrust either my warfarin (or the source) or the meter. I wasn't sure about the strips because they were exposed to a few 90+ degree days. I'll be getting some new strips on Monday or Tuesday and will check then -- but I suspect that my increased dosage will bring me near range.

I strongly suspect that the medication I just started - and upped the dosage on -- probably caused the steep drop. Once I'm back in range, I'll try the medication again, but monitor is closely to make sure that my INR, with the med in my system, stays in range.

(I'm still not sure about activity/inactivity with this low INR, but will do what I have to do and just hold my breath, hoping that there are no clots in my future)

Thanks Dick and Lyn, for your comments.

I'm not an expert, but I don't believe you should have to worry about making any changes in your activity, because of a low INR, unlike you might if your INR was very high with the increase chances of a bleed...I don't thinking doing or not doing any activities would help lower the chances of clots forming.
I know you don't have insurance, but since your INR is basically the same as someone who doesn't take any Coumadin, and since I have NO idea when you started the supplement so how long your INR has probably been this low, IF there was anyway possible to get any lovenox, especially if they could write script for the generic which is much cheaper, I would try to get some.

 

[dick0236]

...... but will do what I have to do and just hold my breath, hoping that there are no clots in my future)
.

I can guarantee that you don't want a clot:eek2:.

I kinda remember reading somewhere that seaweed is very hi in vit K and that it was a product to be careful with...but I am not sure.

I am not sure about activity and low INR. I guess that you will be OK so long as you don't go to any extremes.....:confused2:

 

[Protimenow]

I know when I started that supplement. I only took it occasionally until Thursday, when I took two pills at once. In the past, it was maybe one pill occasionally. I seem to recall something about seaweed and Vitamin K, too, so I've slightly increased my dosage, and will just try not to overexert (so I won't dislodge a clot, if any) for a few days.

Because I didn't take that supplement until the day before my test, I'm pretty confident that the drop in INR has only been for a day or so. I'm hopeful that the effects of that supplement should wear off soon, and my regular warfarin dose will bring it back near my desired range - and that the slight increase this afternoon will bring me back within a couple days. Although I can't afford Lovenox - even the generic - I'll just test a few times this week, to see where my INR has risen to, and to detect any movement towards the top of the range.

Yes, 1.1 is almost like no anticoagulation at all. It was quite a surprise -- and the reason I called the meter manufacturer to see if there may have been issues with the strips and improper storage.

(BTW: I think I had a TIA years ago, when I DID have a doctor and insurance, and my INR was at the high end of my range -- I'm sure that I DO NOT want a clot. )

 

[Duff Man]

dude. I would go to an urgent care NOW to get yourself a script for some generic lovenox. No joke. The cost of generic lovenox will surely beat the hell out of the cost of a stroke.

 

[Protimenow]

I understand your concern. I'm being careful not to do anything that may 'propel' a clot (if this is even possible). Urgent care centers want to be paid up front. So do pharmacies. I don't know of County faciliities that will help me, because I have a house (it's an asset, as far as they're concerned, and if I have any assets, I don't qualify for medical care). I may be sorry later -- but at this point, I don't see any solid options. (Two months ago, urgent care would have been a non-issue - today, it's HUGE).

I may check my INR today - to see if the effect of the stuff I took has worn off, and that the warfarin I took on Wednesday and Thursday (and yesterday) have started to pull my INR out of a danger zone.

I'll post the results later -- If I can.

 

[Jkm7]

Generic lovenox should be on your list of 'to do today' IMO

Best wishes

 

[Protimenow]

I've been told that it's careless, senseless, dangerous, and other terrible things that I'm doing because I didn't immediately run out and start bridging after I had my 1.1 (and 1.3 with a different batch of strips) INR reading. Yes, I was surprised and concerned.

For almost purely financial reasons, I was not able to get medical care or get the generic lovenox that is used for bridging. Instead, I increased my dose of warfarin, avoided situations that would cause my heart to beat quickly or my blood pressure to increase (which would have made it somewhat more likely for a clot - if one had developed - to be dislodged). I also took aspirin and had some wine (the alcohol is also supposed to reduce the effects of Vitamin K, and thus possibly raise the INR).

I've been on pins and needles, and especially careful in my activities, knowing that my INR WILL return to normal in a few days -- but until it does, certainly trying to avoid anything that would cause dislodging of a clot.

If this had occurred two months ago, when I had the financial means to get generic Lovenox, I probably wouldn't have hesitated.

I recall doing research on risks of clotting with the St. Jude Valve in the Aortic position years ago -- and the risk of clotting was fairly low. The problem is -- even though low, if you're one of the unlucky ones, you could throw a clot, which could be fatal or, perhaps worse, just cause a stroke. There's no way of knowing if you're in that group.

The apparent assumption that if your INR is below 2.0, you WILL have a stroke if you don't start immediate bridging seems to be rather pervasive on this forum. The risk certainly increases the closer you get to 1.0, but it's not a sure thing that you'll have a stroke if your INR is low for a short time.

I did more checking and found a paper by Duke University (http://www.gme.duke.edu/newsletters/200901January/Coag Binder 1-09.pdf -- flow chart Appendix A) that recommends a 10%-20% of the total weekly dose added on day One to the daily dose for people testing 1.1-1.4. Since my total weekly dose is 49 (7 mg/day), I should have added 5 mg to my daily dose the day I detected the low INR. There was no mention of bridging. There was no prescription for Lovenox or generic Lovenox for people with 1.1-1.4 INRs. Had I seen this paper on Friday, I would have increased my first day dose from 7 to 12 -- instead, I added the 5 mg over three days. I'll know later today, when I re-test, how successful this strategy is.

Certainly, assuming as other seem to, that you MUST bridge if you have an INR of 1.1, not doing so was careless and dangerous. However, having a 1.1 for a few days does NOT guarantee a stroke. Duke doesn't recommend bridging -- only a one day increase in warfarin dose, followed by a retest in a week or less.

IF you have a doctor or clinic, I certainly don't recommend NOT telling them the moment you have a low INR like the one I had. If I had medical coverage, I certainly would have sought assistance (and this may have been a recommendation of a higher warfarin dose, rather than Lovenox).

My personal situation reminded me of one of my main interests regarding anticoagulation --- anticoagulation management is a public health issue. Testing and management should be available to all who take anticoagulants. If they were, I would have been able to go to my friendly neighborhood anticoagulation clinic, reported my INR, and followed their advice. I wouldn't have had to try to balance the low risk of stroke against the prospect of not having money for food or other medications. Anticoagulation management should be available to everyone.

 

[Protimenow]

Now I'm beginning to doubt my meter. Even though it's four days since I discontinued what I THOUGHT may have made my INR drop, and I've been taken increased doses of warfarin, the INR doesn't seem to be changing. I've even tried new strips that came directly from the manufacturer - and there's still NO change (actually the NEW strips, which were in a hot FedEx truck for who knows how long reported a 1.0). Surely, the increasing doses of warfarin should have shown up in my INR by now -- and my previous dose used to keep me well within range. My INR can't be slipping backwards -- especially if I'm taking warfarin that's been effective for as long as I've had it, and am avoiding anything with properties that can lower my INR.

If I had current strips for my ProTime machine, I'd be testing on it to confirm the InRatio's results.

Have any of you heard of an InRatio 'breaking' and giving results like I'm getting?

I'm getting concerned that, if the meter IS wrong, I may be anticoagulating myself into a range that's TOO high.

I know this is another set of issues than the original low INRs.

If any of you are in the San Fernando Valley and want to swap tests (I'll test you on my meter if you test me on yours), please PM me. In the meantime, I'm trying to find a local doctor or emergency room that can help me confirm my results without expecting immediate payment.

 

[dick0236]

Something AIN'T right:confused2:. You need to get help from a doc, hospital or INR clinic regarding your INR. There must be a social program in your area that can help. You are playing with fire and if you loose.....it's a bitch:eek2:. You might test a "normal" person to rule out machine or strip error, and remember....STROKES are often forever.

 

[kfay]

The ER has to give you treatment whether or not you can afford to pay. If I were you, I would go there now and get tested. Pay the bill off $10 a month.

 

[balloonshark]

Before I was able to get disability I didn't have any money so I couldn't take my coumadin for a month or two. I voluntarily went to a hospital for treatment for my depression and they started me back on coumadin during that week. My INR level didn't come back up so they asked if I wanted to go to the main hospital so I could start a heparin IV. It took another week before my level came back up and they helped me sign up for financial help and told me how I could get help from Bristol-Myers Squibb so I can get my Coumadin.

If your level is indeed low you really should seek help. Some hospitals have a mercy clause which may cover some of the costs if you qualify. Perhaps you can call the hospital and speak with somebody working in the financial dept. and see if they can help you.

 

[Cris N]

So, I am curious, what's your status now? Were you able to get a new test or new warfarin?

 

[Protimenow]

Cris:

Thanks for asking. I've been away from this thread for a few days, and was about to start a new one, reporting on the latest status. Instead, I'll do it right here, where I started it all.

A few things -- although I increased my warfarin dosage with my Indian warfarin (which apparently keeps a LOT of third world people properly anticoagulated and comes in ten pill blister packs), I may not have increased it as aggressively as I should have. I replaced the foreign warfarin with the Barr generic warfarin that I already had. I also got a bit more aggressive about dosing, hoping to raise my INR but not to push it TOO high.

It was a bit troubling, even last night at midnight, to have an INR that was still rather scary.

This afternoon, my tests, using both my old CoaguChek S (which I know isn't to be fully trusted, but for which I had extra strips and figured I'd get a ballpark confirmation that my InRatio was accurate) and my InRatio showed that the INR is, indeed inching up. With a more aggressive increase in my warfarin on Sunday, Monday and Tuesday, my INR is moving closer to range. I expect to be 2+ in the next day or two, and will watch to be sure I don't move too far above 3.5 or so, when the doses in the last day or two take full effect.

I've done some research into the risks of such a low INR and have come up with some more information (much of which doesn't indicate that bridging is necessary in situations like mine).

Here's some of the most important information:

Duke Medical doesn't advise to bridge unless some kind of procedure is scheduled. They advise to add 10-20% of the weekly warfarin dose to the first day's medications for people with INRs from 1.1-1.4. They advise a retest in a week (or sooner).

In a short book on anticoagulation, it states that the risk of stroke is least for a person with a bi-leaflet valve (like the St. Jude in my chest) in the Aortic position (mine is an Aortic valve). They also state the the greatest risk is in the first three months after implantation -- for me, it'll be 20 years this month. There are extra risks for pregnant women (did you ever hear of a pregnant MAN?), for people with multiple mechanical valves, and for people with mechanical mitral valves. I won't even mention the risks for people with A-Fib (because I don't have A-Fib). In my case, the profile described as least at risk is the one that applies to me.

Although I was really concerned that I wasn't able to rush to a doctor or emergency room for testing and possible lovenox injection(s), it's possible that, if the doctor at the ER was on top of things, I would have been sent home with a higher dose of warfarin and instructions to test again in four days. Lovenox is not without its own risks, so I may have been better off without it.

---

I appreciate the concern. I've been careful (and almost always concerned about my INR) this last week. I've suspected the InRatio meter or strips to be faulty - but at this point, I have my doubts (because the CoaguChek S results were similar, and because I was able to test with new strips). I hope that this never happens again, and I'm not sure why my INR fell as abruptly as it did. I hope it never does again--but if it does, I'd like to identify and avoid the cause of the drop. (I don't know if it's as simple as stress and dehydration - but as you can see from some of my posts, the stress has been pretty severe)

 

[Cris N]

Are you still taking the seaweed supplement?