Dosing Question

[Unicusp]

Just wanted to run this by the experts. I'm still relatively new to this fun of Warfarin dosing and I'm sure that my body is still adjusting.
My targeted INR range is 2.0 to 3.0
For now, it appears that a steady daily dose of 3.0mg leads to a higher INR above 3.0 and a steady daily dose of 2.5mg leads to an INR around 2.0
So, the question is, are there any issues with alternating dosing every other day?
For example: Mon: 2.5mg Tues: 3.0mg Wed: 2.5mg Thurs: 3.0mg Fri: 2.5mg and so on.........
Or is it better to do 3 or 4 days in a row of 3mg followed by 3 or 4 days of 2.5mg?
I'm thinking alternating will be tighter and less deviation. Assumes of course consistent diet.
Thoughts / comments?? Thanks!
Latest tracking chart below:

 

[Superman]

No issues. I keep 5’s and 1’s on hand and will alternate 5, 6, or 7 mg’s as the need requires. For a while I was on 6 mg’s daily with one day at 7 mg’s.

I call this weekly dosing. Pellicle hates that. . Seems to think it’ll lead to folks taking 42 mg’s on Monday and skipping the rest of the week.

 

[pellicle]

For now, it appears that a steady daily dose of 3.0mg leads to a higher INR above 3.0 and a steady daily dose of 2.5mg leads to an INR around 2.0

wow ... that's volatile

are you sure of this? Because this is how I read your graph (and man doesn't the American Date format just shine out as rubbish when trying to read those axes ... everything starts with months, the number changing is buried in the middle ... what a cocksup that system is)

Firstly I see this

1. why that sudden drop in dose there? (under why)
2. the decline is in order with anticipated (and reported by me in my blog posts) decline rates
3. the increase is also consistent with my reported findings of delays in starting and rates of change.

to me you are micro managing this and (as I say in my blog posts) you need to keep a steady hand on the tiller. Measure weekly and adjust weekly is where I'd start you.

Also:
How long are you out of surgery?
Do you know if your blood serum albumin is returning to normal yet?
Why have you chosen 2.5?
What are your available pill dose sizes? (brands vary)

I also feel that (for presentation) you need to make those graph lines a little bigger and consider a bar chart for the INR on that ... (keeping the doses as a line).

Please consider re-reading this blog post and look out for my points about "simple harmonic motion" (meaning a yoyo ... which is what you are inducing from your over enthusiastic corrections)

http://cjeastwd.blogspot.com/2014/09/managing-my-inr.html

My view is that people can read that and I estimate take away 10% each time they read it. It can be read and re-read with barely any change in "take out", but in combination with practical (which is why at Uni we do classes and prac) you start to see questions, in which case the answers start to make sense. Once they learn more from doing then some of that stuff is "light bulb" moment of "oh yeah" and you've just got another 10%

Best Wishes (reach out if you want to work together)

 

[pellicle]

Pellicle hates that.

almost as much as I hate US Date format

• dev rant
• reddit
• monopolatu

there really is no defence for it aside from the argument that when some people speak they speak April first ninteen fifty six.

nobody else uses it ...

https://en.wikipedia.org/wiki/Date_format_by_country

 

[Warrick]

I cant be bothered breaking tablets in half so I find alternating dose like 9mg one day and 10mg the next works well if I think I need a half mg in there.
Im lucky I’m on around 10mg a day so its easier to make dose adjustments with full tabs, me I find 8mg daily not enough and 11mg too much so my goldilocks dose is anywhere inbetween
Whereas my fathers dose is between 2.5-3mg warfarin a day which can make it a bit trickier.

 

[Unicusp]

I also feel that (for presentation) you need to make those graph lines a little bigger and consider a bar chart for the INR on that ... (keeping the doses as a line).


Best Wishes (reach out if you want to work together)

Thanks for your feedback. Much appreciated! I made your suggested changes to date format (also US Military format) and added bars for INR level. Good suggestions.
I will reread that blog post. Thanks.
Here are brief replies:

1. why that sudden drop in dose there? (under why) >> because INR was 3.8 and 3.9 5 days earlier
2. How long are you out of surgery? >> 5 weeks on 26-March
3. Do you know if your blood serum albumin is returning to normal yet? >> No, have not had a comprehensive blood test yet. Scheduled for 15-April
4. Why have you chosen 2.5? >> because 3.0mg results in higher INR of 3.8/3.9
5. What are your available pill dose sizes? (brands vary) >> I have 1mg tabs and 5mg tabs, and a pill cutter

 

[dick0236]

I'd try alternating 2.5 and 3mg every other day. Get a seven day pill box to keep track.

 

[Unicusp]

I'd try alternating 2.5 and 3mg every other day. Get a seven day pill box to keep track.

Thanks. That was my thought as well.

 

[NorthWoods]

Don't feel bad. My dosing has been all-over the place. I started on 7.5mg in the hospital. Then sent home and was told to take 6mg daily. Holy crud... that let to INR of 4.4. Some weeks my INR is 3.2, or a 2.5. It's all a guessing game till they figure it out.
My doctor has said that Warfarin is weight based... which a lot of it he is right.
Right now I am alternating 2mg 3 days a week and 4mg 4 days a week. I have a feeling it will still be on the high side when I get checked tomorrow.

 

[RAS]

5 weeks since surgery may be too soon to expect stability.

Splitting pills is easy, but the active ingredient is not guaranteed to be evenly distributed.

Consistency of dosing and testing is key.
Example :You could try 3 mg 4 days/week (i. e. M/W/F/Su) and 2 mg 3 days per week.
That way you will have the same dose per week and avoid splitting pills.

Test once per week, same test day, same test time each week if possible

Testing more frequently given the lag in INR effect will lead to a desire to "correct" dosing that may be just fine if given enough time to work.


Whatever dose regimen you decide on Don't be too quick to change dose unless way out of safe range.

 

[Aalok jain]

Just wanted to run this by the experts. I'm still relatively new to this fun of Warfarin dosing and I'm sure that my body is still adjusting.
My targeted INR range is 2.0 to 3.0
For now, it appears that a steady daily dose of 3.0mg leads to a higher INR above 3.0 and a steady daily dose of 2.5mg leads to an INR around 2.0
So, the question is, are there any issues with alternating dosing every other day?
For example: Mon: 2.5mg Tues: 3.0mg Wed: 2.5mg Thurs: 3.0mg Fri: 2.5mg and so on.........
Or is it better to do 3 or 4 days in a row of 3mg followed by 3 or 4 days of 2.5mg?
I'm thinking alternating will be tighter and less deviation. Assumes of course consistent diet.
Thoughts / comments?? Thanks!
Latest tracking chart below:

View attachment 887658

Same happen with me these days .Last week i am on 3mg each day my INR was 3.1 . So I am on 3mg 5days and 2 mg 2 days and will check my INR this week.

 

[NorthWoods]

5 weeks since surgery may be too soon to expect stability.

Splitting pills is easy, but the active ingredient is not guaranteed to be evenly distributed.

Consistency of dosing and testing is key.
Example :You could try 3 mg 4 days/week (i. e. M/W/F/Su) and 2 mg 3 days per week.
That way you will have the same dose per week and avoid splitting pills.

Test once per week, same test day, same test time each week if possible

Testing more frequently given the lag in INR effect will lead to a desire to "correct" dosing that may be just fine if given enough time to work.


Whatever dose regimen you decide on Don't be too quick to change dose unless way out of safe range.

Exactly... That's what I keep telling the INR nurse but they seem to think that after a month everything should be stable.
I do get tested twice a week (Tuesdays and Fridays). I only have the 2mg pills so no splitting yet. I keep my diet consistent, have one beer a week, but my doctor says they still have me too high on dosing.

 

[pellicle]

Hi

Thanks for your feedback. Much appreciated! I made your suggested changes to date format (also US Military format) and added bars for INR level. Good suggestions.

and please do forgive my little rant about US Dateformat ... bottom line is that if you feel comfortable using it then do so. I happen to use what seems to be US Military format

Dick raises the point on pill boxes, something I also bang on about and am surprised that its not in my own blog post, I believe this post:
https://www.valvereplacement.org/threads/missed-a-dose-what-to-do.865595/post-865636
makes the points well. A search (using Google) will reveal that everyone things its a good idea (except perhaps newbies who think it somehow signals "being old"). Dick makes this point:

https://www.valvereplacement.org/threads/may-have-forgotten-warfarin-for-two-days.887140/post-889115

A pill box is the smartest....and simplest thing we can do to solve one of the biggest problems with warfarin..."did I take my pill today???".... ​

​

why that sudden drop in dose there? (under why) >> because INR was 3.8 and 3.9 5 days earlier

ok, well I do wish I could talk because talking is much friendlier than typing. So firstly don't make big changes to your dose unless you want big changes to your INR. These changes often take days to sort out.

How long are you out of surgery? >> 5 weeks on 26-March

why are we seeing data for 25th of Feb then?

Anyway its still early days, don't be afraid of the INR being just a weeee tiny bit out of range on the over side and refer again to the graph for why. I would call this an over-reaction

Do you know if your blood serum albumin is returning to normal yet? >> No, have not had a comprehensive blood test yet. Scheduled for 15-April

ok, no biggie, I thought it was you who (to my surprise) actually knew their serum albumin ... maybe I got that wrong. Its not really important but as I said in that post its a cornerstone of INR stability and will change as you recover - meaning your dose will change.

Why have you chosen 2.5? >> because 3.0mg results in higher INR of 3.8/3.9

well then, as I said there is not sufficient evidence as I saw it to be sure of that. I believe what we are seeing is a yo-yo effect.

What are your available pill dose sizes? (brands vary) >> I have 1mg tabs and 5mg tabs, and a pill cutter

I suspect you're saying "what I have on hand is" which isn't quite what I asked. Assuming its what I asked that's a bit gross I'm unaware of any brand that only offers that pair of choices. My brand for instance offers 1 3 & 5. With this selection in your pill colour palate you can make nice sizes easily.

I don't see anything wrong with alternating doses (in your pill box) so that you can do (say) 2.5 | 3 mg if 2.5 is too low and 3 is too high. With such small doses its going to be difficult to shave it in.

I like the new graph

View attachment 887662

please if you want more than 2 sentence answers and proper answers I encourage you to reach out, >>and we can talk <<

So looking at your new graph I see that you've been adjusting down from an INR of about 4.8 and a dose of 5mg (yes?)

I think I see your logic in dose adjustments there but I disagree with your use of the trendline in such wildly varying data.

INR is creeping up 22 ~ 26th but you've made a rather GROSS adjustment of increasing and or decreasing by 50% ... that's a lot. Tweaking a dose is normally smaller ... like 10% that will be tricky with your dose being so low.

So I would concur with Dick and say alternate 2.5 | 3mg and see what that yeilds. But stay on that for at least 5 days before seeing. Measure as often as you like but if you start moving your dose all over the place it'll be like watching a kid doing a burn out in a rear wheel drive car and slewing all over the place (not a graceful drift like we wish). This is because of the inherent lags in the system.

Lastly, I don't like writing multi page essays only to have my first sentence assumption wrong, second guessing what something means and not really knowing the level of communications best suited to the task.

I don't know why people are afraid to talk and I'm offering to make the call on my coin or WhatsApp which just uses your WiFi.

To make better calls at dosing we need more data (like weeks or months of it) and like I said adjustments should not be made willy nilly because you get the sort of yo yo we're seeing here.

Best Wishes

 

[pellicle]

Same happen with me these days .Last week i am on 3mg each day my INR was 3.1 . So I am on 3mg 5days and 2 mg 2 days and will check my INR this week.

please make sure you make those days alternating, not 3mg 5 in a row and 2mg 2 days in a row.

 

[pellicle]

My doctor has said that Warfarin is weight based...

if you mean your body weight, yes, but that's nowhere as significant as what genetics you have for the cytochrome variants. Ultimately using weight as any sort of guide is not meaningful because the intention is INR. The weight thing can be helpful when initiating dose, but once on warfarin the only value of importance in dosing is INR

 

[Aalok jain]

please make sure you make those days alternating, not 3mg 5 in a row and 2mg 2 days in a row.

Yeah i am aware of that.
My cardio suggest me to change at most 15% of your dose a week so last week i am taking 21 mg and this week i am on 19mg.

 

[pellicle]

My cardio suggest me to change at most 15% of your dose a week

I agree with your cardio

 

[NorthWoods]

My INR nurse has been changing the dosing at the same 15% for me as well. I think a few more weeks and it should be stable between 2.0-3.0

 

[Aalok jain]

Don't feel bad. My dosing has been all-over the place. I started on 7.5mg in the hospital. Then sent home and was told to take 6mg daily. Holy crud... that let to INR of 4.4. Some weeks my INR is 3.2, or a 2.5. It's all a guessing game till they figure it out.
My doctor has said that Warfarin is weight based... which a lot of it he is right.
Right now I am alternating 2mg 3 days a week and 4mg 4 days a week. I have a feeling it will still be on the high side when I get checked tomorrow.

You can take 3mg each day as 3mg pillls are available.

 

[Protimenow]

I agree with Pellicle - varying doses on different days isn't a good idea if you want to be able to test accurately. This is because your INR will fluctuate in response to your dosing - one day may be higher (or lower) than the day before it. You won't get an accurate idea of which dose is right for you.

I wouldn't be concerned with an INR between 3.0 and 3.5 (and probably an INR before 4.0). Risk is still low. Your clotting time will be slightly longer than it would be with a 2.5 - but you probably won't notice any difference.

And, as others have said, it may be too soon after surgery to be able to establish stable dosing.

I have warfarin in varying strengths. for a while, I was taking 6.75 mg/day - this was 1/2 of a 7.5 mg pill (3.75) plus a 2 and a 1 (or 1/2 of a 4 mg plus a 1 mg).

If you split your pills, the difference in dosing between the 'bigger' half and the 'smaller' half won't be enough to cause a real change in INR.

Pick the daily dose that keeps you in range - even if it takes more than one pill to do it. Remember, though, that for unknown reasons, your INR may change and you may have to change your dose.