changes in INR within a week.

[Dunwanted]

Hello everyone,

Just wanted to seek some knowledge from those of you with more experience with warfarin and INR.

I do my tests every Friday at 12 ( right after my cardiac rehab does this affect the result since it's like 30 mins after it).
My test this last Friday gave a result of INR 4.1 which is too high, my cardiologist told me not to take warfarin for two days which i thought it was a little excessive but i followed through anyways, so i did not take my warfarin Friday and Saturday then continued my regular dose for the remaining days (Sunday, Monday, Tuesday and today I took 2.5 more than normally) my test i did today just 4 days after the last test gave a result of 1.7 INR which is too low as i need to have it above 2 all times.

I also got my coagu chek machine which i did two test today, first one gave a result of 1.8 INR but i felt like that test was done wrong since the blood drop stayed a few seconds on my finger and the second test i did it better and the blood drop went immediately front my finge to the strip and this one gave me a result of 2.0 INR.
These test were done 3 hours after the lab blood was drawn and I did not have the lab results by then.

Can this happen? Is it normal?

I believe the lab did the test wrong or there was some type of mix up since my previous test was 2.7 INR then the week after 4.1INR and 4 days after 1.7 INR i feel like the change is too drastic and the 4.1INR from the lab was incorrect.
Also with my INR this low what should I do?

 

[dick0236]

Please provide a little more info.......
What is your prescribed INR range?
What is your prescribed warfarin dosing?
What is the Brand of your mechanical valve?

My hunch is that the initial instruction to "hold two days" was excessive for a 4.1 INR and drove your INR very low......

 

[Dunwanted]

Hello Dick,

sorry now that i read my message i notice is lacking information and bit all over the place.

My prescribed INR is 2.0 -3.0 (prescribed by cleveland clinic surgeon)
My prescribed dosing is 5 mg every day
ON-X Mechanical valve

yes i also think hold two days was a bit excessive, i am starting to realize that my local cardiologist does not have much experience with warfarin dosing (she says my ideal INR should be 3.0)

 

[dick0236]

According to ONYX the 1.7 INR should keep you out of trouble.......but to be safe I would increase my weekly dose(35mg) by 15%(5mg) now and recheck in a week. If you still need to raise your INR then increase it slowly, 5mg per week, until you get back in range. My own experience is to make adjustments slowly to minimize a "yo-yo".

Hopefully, others (Pellicle) will come by and give you their input. I have learned that, with my old valve, to move slowly when making changes plus I am also old and becoming very resistant to major changes.

 

[Dunwanted]

Thanks for the advice Dick.

Yeah i totally agree making slow changes is better, i ended up complying with what my cardiologist told me because my family was pushing me to do that, but slowly i realize that i can try to self manage since i am the one with the issue and the one who has to live with this and learn how it work since im the one can have the serious repercussions if im out of range.

 

[ATHENS1964]

If I had 4.1 INR, I would repeat the test and only then would I reduce the dose a little for one day, I would also eat a little more vegetables with vitamin K and in 2 days I would check again.

 

[pellicle]

My test this last Friday gave a result of INR 4.1

of course it can happen, but that's not drastic.

going to INR = 9 in a week is drastic.

There is too little information here to make more comments, but if you decide you want to get back to the sheet we were working on, my door is still open.

i am starting to realize that my local ...

is exactly like every experienced INR self managing member here has said ongoingly since for like the last 15 years or so?

 

[pellicle]

If I had 4.1 INR, I would repeat the test and only then would I reduce the dose a little for one day, I would also eat a little more vegetables with vitamin K and in 2 days I would check again.

agreed .... or maybe make a small dose change (10 ~ 20% or so) certainly nothing like
" not to take warfarin for two days "

 

[pellicle]

which is too low as i need to have it above 2 all times.

also this is just plain exaggeration. If you use superlative language like "at all times" it just heightens and feeds unrealistic anxiety.

Many of use here have had procedures which >require< your INR to be less than 1.5 (you and I have even talked about exactly this if memory serves). This is not how INR works and you don't suddenly become a walking blood clot at INR = 1 you indeed have time.

This is actually the basis of bridging therapy (which may not really be needed if you acquire the skill of self management); you bring your INR down to 1 (if you follow those directions) and commence heparin before it falls below 2. You have the procedure where your INR will remain around 1 for some time because coagulation is required for your survival.

Then when the surgeon doing the procedure has determined that sufficient time has passed your can re-commence anticoagulation therapy (in the form of Heparin) and begin taking your warfarin. In this very aggressive system (suitable for very high risk patients which to my understanding you are not) you remain on Heparin until your INR reaches therapeutic range (which I'd estimate at INR >= 2 but On-X will tell you is 1.8). At this point Heparin is discontinued.

However if you read the post (which I understood you have read) here
https://cjeastwd.blogspot.com/2017/12/perioperative-management-of-inr.html
you'll see that I cite this article within it:
https://www.nps.org.au/australian-p...e-perioperative-management-of-anticoagulation
which makes very obvious points like:

Do the benefits of anticoagulation outweigh the risks?​

The approach to the management of anticoagulation in patients with prosthetic valves undergoing non-cardiac surgery remains controversial. The need for perioperative anticoagulation in patients with mechanical heart valves has been questioned in a recent review. The authors argue that for every 10 000 patients with mechanical heart valves who are given perioperative intravenous heparin, three thromboembolic events are prevented at the cost of 300 major postoperative bleeding episodes​

Those are their words not mine:

I believe that its important to not only ask questions, but listen to the answers and either challenge them for their veracity or believe them; not just dismiss and forget them.


Best Wishes

 

[Dunwanted]

Hello everyone thanks for your feedback

also this is just plain exaggeration. If you use superlative language like "at all times" it just heightens and feeds unrealistic anxiety.

I do realize the wording may have been incorrect already changed it in the thread.

There is too little information here to make more comments, but if you decide you want to get back to the sheet we were working on, my door is still open

Thank you very much one again for that offer, i will gladly take you on it, I'll fill it today.

I was a bit overwhelmed when i did this post as my INR hasn't changed this much before and 1.7 INR was the lowest it has been after coming home after surgery

 

[Chuck C]

Hi.
Just to add my two cents. I would fully agree with Dick's comment and others that holding two full days is excessive. I would expect that would send many folks below range within a few days, even with a starting INR of 4.1. We all clear warfarin at different rates. I know from testing myself that if I held my dose for two days, I would likely be under 2.0, even if I had a starting INR of 4.1.

A brief visit to 4.1, followed by a brief visit to 1.7, is nothing to be alarmed about. Following release from the hospital, I was put on a relatively high dose of amiodarone, and my INR shot to 9.7 within 3 days. A prescription of vitamin K then brought me down to 1.6 and then an overcorrection of that low brought me to 5.0, before things got back to normal. At 9.7 I was at significant risk, particularly if I would have hit my head or something during that time, which I tried my best not to do. At 4.1 INR, you would be at sligtly more risk than your normal range of 2.0-3.0, but only marginally. Similar to your low of 1.7, a brief visit adds a little more risk, but very little. I had a thyroid procedure and as as an alternative to bridging I brought my INR below 1.5 for the procedure, down to 1.4, and stayed there for a day.

Generally, it is the folks who stay out of range for long periods who are really at risk. Think about the folks with your valve, On-X, who are getting poor guidance and staying at 1.5-2.0. That is month after month, year after year. There is a much higher risk of a clot when one stays there. A brief visit above or below range, statistically not much added risk. This is the one of the primary reasons why those who self test weekly have far fewer events than those who go 4-6 weeks between tests at the lab.

I think the take away, as Athens has suggested, is to test again and then make small adjustments when we get an unexpected reading like that. Then, test again after a few days and tweak minimally again if needed. There are some people who stay near INR of 4.0 all the time, due to higher risk of clotting, and it is not a zone that should cause anyone to panic, but common sense in being a little more careful would be wise.

 

[Dunwanted]

Hey Chuck thanks for you feedbac it really helps.

I think I was over worrying because of the my doctor's reaction when my INR was 4.1 telling that i have to be extremely careful and staying far from sharp objects the she got surprised again when it dropped to 1.7.

Also I don't really trust the medicine in my country in case any emergency would happen (i live in a 3rd world country).

But today reading all the responses has me a lot calmer.

 

[pellicle]

Morning

I was a bit overwhelmed when i did this post as my INR hasn't changed this much before and 1.7 INR was the lowest it has been after coming home after surgery

I understand, and my purpose was to steady the minds of other readers who will read implicitly in what you wrote "oh, wow, so I do need to panic"

This whole problem (of which you suffer too) comes from the (hyperbole warning) morons in medicine who think that its a good idea to instill the sense of fear into everyone because they want to enforce compliance in taking the prescription.

A section from my book:

In my view you want people to be on board of their own free will and committed to doing the right thing (in this case “doing right by and for themselves”). Sadly, the most common strategy I see being used to motivate patients is that of fear. Studies on that show while it's a powerful motivator it's not a good one for several reasons. For starters a Google search on “why fear is not a good motivator” will bring up many points like:​

​

• It creates chronic stress leading to burn out
• Promotes a feeling of powerlessness
• Inhibits ability to think clearly
• Makes people more likely to lie
• The strength of the influence of fear diminishes in power when nothing goes wrong

Your cardiologist has fulfilled every expectation of a cardiologist I have: specialise in the issues of the heart both hydro-mechanical and electro-chemical, but have not the faintest clue about pharmacokinetics or drug titration doubled up with having zero actual experience either.

If they don't admit that they don't know then they are puffed hubris filled fools.

 

[ValveAdmin]

Please remember that our members are not doctors and their information is from their research and things that have happened to those they know and themselves.

Any medical advice given and used is for you to choose after discussing with your own doctor/s. We do not endorse any medical information given.

 

[user 15848]

According to ONYX the 1.7 INR should keep you out of trouble.......but to be safe I would increase my weekly dose(35mg) by 15%(5mg) now and recheck in a week. If you still need to raise your INR then increase it slowly, 5mg per week, until you get back in range. My own experience is to make adjustments slowly to minimize a "yo-yo".

Hopefully, others (Pellicle) will come by and give you their input. I have learned that, with my old valve, to move slowly when making changes plus I am also old and becoming very resistant to major changes.

Hi, i did follow the 1.5 -2.0 during the first year with my on-x, but was always concerned about going below 1.5; so my target number is 2.0, some times it goes up to 2.7 and then i reduce the dosage 0.5 mg for 2 days, and some times, 6 DAYS AGO, went down to 1.6, and added 1mg for 2 days, "This is just what works for ME, we are all different"; and today is 2.3 and thats it. I also used to test every 10 days to save on $ for the test strips, but listened again to Pellicle, and now i am doing it every 7 days; at home during fall-winter, in the lab spring-summer just to save some $ and because is easy for me to take an street car in Toronto and get to the lab, for now; 10 years from now, i ll be only doing it at home, Just sharing my brief experience over past 8 years.

 

[Dunwanted]

This whole problem (of which you suffer too) comes from the (hyperbole warning) morons in medicine who think that its a good idea to instill the sense of fear into everyone because they want to enforce compliance in taking the prescription.

A section from my book:

In my view you want people to be on board of their own free will and committed to doing the right thing (in this case “doing right by and for themselves”). Sadly, the most common strategy I see being used to motivate patients is that of fear. Studies on that show while it's a powerful motivator it's not a good one for several reasons. For starters a Google search on “why fear is not a good motivator” will bring up many points like:​

​

• It creates chronic stress leading to burn out
• Promotes a feeling of powerlessness
• Inhibits ability to think clearly
• Makes people more likely to lie
• The strength of the influence of fear diminishes in power when nothing goes wrong

Your cardiologist has fulfilled every expectation of a cardiologist I have: specialise in the issues of the heart both hydro-mechanical and electro-chemical, but have not the faintest clue about pharmacokinetics or drug titration doubled up with having zero actual experience either.

If they don't admit that they don't know then they are puffed hubris filled fools.

yeah i did not like the fear as a motivation and i did feel most of the things you brought up in the points.

Still dont get me wrong i will still follow up with my cardiolgist for the regular check up, she has done an amazing job so far with everything else, i just feel like she isnt experienced enough with warfarin which is to expected as there isnt many people with a mechanical valve in my country.

 

[pellicle]

Any medical advice given and used is for you to choose after discussing with your own doctor/s. We do not endorse any medical information given.

I heartily agree and I'd go one step further and say;

"any advice given is not medical advice, but our opinions based on our own experiences. All participants or even readers should take this only as information based on our personal experience and use this to inform your discussions with your Cardiologist or Surgeon. Remember, even surgeons and cardiologists will make different recommendations on the same examination and data; that's why we get second opinions"​

 

[sharky7]

also this is just plain exaggeration. If you use superlative language like "at all times" it just heightens and feeds unrealistic anxiety.

Many of use here have had procedures which >require< your INR to be less than 1.5 (you and I have even talked about exactly this if memory serves). This is not how INR works and you don't suddenly become a walking blood clot at INR = 1 you indeed have time.

This is actually the basis of bridging therapy (which may not really be needed if you acquire the skill of self management); you bring your INR down to 1 (if you follow those directions) and commence heparin before it falls below 2. You have the procedure where your INR will remain around 1 for some time because coagulation is required for your survival.

Then when the surgeon doing the procedure has determined that sufficient time has passed your can re-commence anticoagulation therapy (in the form of Heparin) and begin taking your warfarin. In this very aggressive system (suitable for very high risk patients which to my understanding you are not) you remain on Heparin until your INR reaches therapeutic range (which I'd estimate at INR >= 2 but On-X will tell you is 1.8). At this point Heparin is discontinued.

However if you read the post (which I understood you have read) here
https://cjeastwd.blogspot.com/2017/12/perioperative-management-of-inr.html
you'll see that I cite this article within it:
https://www.nps.org.au/australian-p...e-perioperative-management-of-anticoagulation
which makes very obvious points like:

Do the benefits of anticoagulation outweigh the risks?​

The approach to the management of anticoagulation in patients with prosthetic valves undergoing non-cardiac surgery remains controversial. The need for perioperative anticoagulation in patients with mechanical heart valves has been questioned in a recent review. The authors argue that for every 10 000 patients with mechanical heart valves who are given perioperative intravenous heparin, three thromboembolic events are prevented at the cost of 300 major postoperative bleeding episodes​

Those are their words not mine:
View attachment 889148

I believe that its important to not only ask questions, but listen to the answers and either challenge them for their veracity or believe them; not just dismiss and forget them.


Best Wishes

I have had from the beginning a problem, not being a medical Pro of any sort-so not exactly as to why I felt this way, with using those shots and worrying about being off of warfarin for as little as less then one week/month! I believe the risk is very small at best, and at worst, the same odds of someone that perhaps should be on some blood thinners and go without, cause a doctor has not figured out yet that they need to be on them!
And it is not because I hate shots, i dont mind them, i may not be able to explain it but I just am not comfortable in taking those shots instead of Warfarin when having a procedure that needs me off of it! [something in my brain is telling that I dont need it, then post surgery, etc. I take it again either late that day, or the next day!
Now with what you have shown us, I believe that we all out here are not being made aware of everything that we need to know, and those doctors/surgeons are making the decision/s for us, instead of allowing us in on it at any stage! THEY think we are too dumb to understand or what?? WOW, am i angry with this new information learned here, no but I am a bit confused as to why this is going on!
I would add now and at this point, thank you for everyone here and in doing what ya all do and say, I believe this brings us all back to having more control in what we do and do not do in our lives, and of course concerning our OWN health, and that of our loved ones!!! Having the right to decide for our selves what is best for ourselves is a very important thing, and it should not be taken away from anyone, at any time, informed enough to decide is what we all strive for, ain't it????

[this is to pellicle and no one else, i dont want this to get out, k everyone??
When I first got on and started using WARFARIN, my heart doctor then was testing my INR every 6-7 months or so, and I had no idea as to what was going on, no matter what number would come up, he would state, we are all good here [he didnt even tell me that my INR should be this or that, nothing.], and there was no problem. And this went on for a number of years[7+] like that. then I got with the VA and their doctors and it all started, if I was low or high, they wanted me to take more or less then be tested ASAP,[within a weeks time] and I live not exactly around the corner to the VA, so this got old very fast! Point being, not sure now if there is one there, just felt like I had to tell someone, and right now you are that someone, thank you for the ear, i feel much better now!]

 

[pellicle]

Hi

WOW, am i angry with this new information learned here, no but I am a bit confused as to why this is going on!

well here's the thing, there is resistance to being up with best practice for so many reasons, not least the time involved for the clinician. Then there is the psychology of clinicians involved in INR, they really are at the bottom of the Hospital Pecking Order. You'll probably notice that even orderlies at the hospital are more powerful.

Basically surgeons shrug off INR to someone else, and nurses too are only involved gathering the information and plugging it into a system which tells them what to do. They literally have no clue. I learned recently in the UK that one such system (called Dawn) has a claimed efficacy of <55% in range. Wow ... I can do about that with my magic 8 ball INR method for dosing management:



Even Chuck advocates it
https://www.valvereplacement.org/threads/my-avr-ohs-experience.888563/post-916603


Given that nobody in the structure takes accountability for your INR swings, and worse how many people just don't do what they're told we have the situation we are in now.

Another way to look at it is this: the data shows that the biggest problem is patient compliance (taking their drug) and so from the perspective of a bureaucratic and authoritarian institution like a hospital taking control out of your hands and investing it in their hands is the "safest way" (as they see it).

informed enough to decide is what we all strive for, ain't it????

informed is really a vexed question for so many reasons, not least of which is you are in a position of confusion and from what I've read here utter irrational panic in some cases.

I'd say that this persists well after surgery with the stories we tell ourselves to firm up the confidence we've mad in our decision of who to believe.

Ultimately that is what this place really does. Gives a place where you can rub shoulders with actual people, see and observe what they did and why and then make up your own mind about what you learn here.

Best Wishes

PS don't forget this perspective from Hospital Administration

 

[pellicle]

hey @sharky7 , may need to refresh the page to catch my update on that post