Help?

[mecretired]

I am a newby to Warfarin. I had surgery on May 3, 2010 to replace my ascending aorta and aortic valve with an SJM grafted valve. Right now the "coumadin clinic" associated with my doctor's office is monitoring my dosage. I go into the lab for INR checking once per week. The clinic then calls to tell me what my dosage should be for the following week. My INR is supposed to be between 2.5 and 3.5. I had been at 3.3 for 2 wks then it went to 4.9. I really don't know what caused the difference but have lots of questions. I have a long list of foods that contain Vit K and a long list of medications that will thin the blood. One of my questions is "Can I have a serving of spinach (or any of the other foods on the list) one evening/wk without worrying about changing the dosage?" I really don't want to have to eat a serving every day/I would rather give up all those foods. Also, what OTC meds do you take for headaches/muscle aches, etc.? Can you drink any amount of alcohol without it affecting your INR? Prior to surgery, my surgeon told me it wouldn't be a problem for my husband and I to share an occasional bottle of wine. The more I read, the more discouraged I get. So, HELP?:confused2:

 

[ARGreenMN]

Hi. Not sure how much help I'll be (or at least how reliable) since I had my surgery 2 days after you But here's what I've been told. Again, I'm no pro at this, still learning, so take it with a bit of a grain of salt 'till some ol' veterans confirm.

First, on alcohol, I've been told several times now (by several diff. docs) that it's ok to have an occasional 2-3 drinks in a given night, but if you get beyond that it gets dangerous. My understanding of the danger is that alcohol further thins your blood. And if you're already anti-coagulated like we are, you start running the risk of things like internal bleeding with more than 2-3 drinks. And, if you were to happen to get cut it could bleed pretty bad. I think there's some other risk factors w/ more alcohol than 2-3 drinks (something with the stomach - like ulcers?).

I've been lucky with mine, but I've heard a lot of folks have trouble keeping their INR in range, so I don't think you need to be too concerned. What you're experiencing sounds pretty normal from what I've heard. It'll be a challenge for a while 'till things get regulated.

On spinach and other things high in Vitamin K, my understanding is the key is consistency. And to be honest, I've got the same question as you - what if I want it consistently once or twice a week... Will have to rely on others to answer that. But - since you're so high right now, I'd guess a serving of spinach would be fine right now for you (since vit. K lowers your INR). It would be more of a risk if your INR was towards the low end of your range. But not sure about having it once a week once you get your INR steady - that might mess with it...

On OTC meds for headaches, tylenol (or generic acetaminophen) seems to be the one they recommend. Which sucks, cause it doesn't do much for me... I've been wondering myself if I could get a prescription for something stronger - cause I've been having headaches and Tylenol isn't cutting it. I've got some Vicodin left, but that seems like overkill. So not sure I can help with this one. Will be interesting to see what others say...

 

[Cris N]

Please don't get discouraged... it's really not as bad as you think. If you haven't looked at this thread yet, you should http://www.valvereplacement.org/for...adin-It-s-Not-To-Be-Feared.-Please-Read-First

Now, on to some specifics... enjoy your wine... just don't overdo it.

Most docs will tell you acetaminophen (Tylenol) for everyday pain relief. If I'm really in pain I add ibuprofen to the mix. It hasn't caused any problems with me. Actually, during the summer when I golf a lot I take both almost every day (I have a bad back). The issue with ibuprofen (and aspirin) is that it can cause stomach irritation and perhaps bleeding.

You are still pretty new out of surgery... INR can be somewhat tricky while you're recovering. A number of factors can cause it to spike like yours did... the most common is the accidental doubling of doses. There's some anecdotal evidence that hot weather can trigger a rise in INR. So can being sick or perhaps other medications that you're taking - even ones that may surprise you. Antifungals are notorious for their interactions.

About that list of Vit K amount found in food. It makes for interesting reading... it is helpful to have a general idea of the amount of Vit K just so you don't get blindsided. But other than that, please don't select your food based on the list. The phrase we use a lot around here is 'Dose the diet, don't diet the dose." The spinach, or any other food, (on or off 'the list') should be consumed in an intelligent manner. You've heard/read that the one of the keys to successful INR management is consistency. That doesn't mean you have to eat spinach every day, or never eat it. It means that you should consider what you eat and try to keep it somewhat consistent on a weekly basis.

Back to your 4.9 reading. I mentioned that there may be something that caused it... what is your dosage per day? I see that you take verapamil - anything else? Creams, herbals, supplements, vitamins...

Another real possibility is that the reading was faulty. It would not be the first time:rolleyes2: that someone had an erroneous reading. How did the clinic change your dosage as the result of the 4.9 reading?

Hang in there...

 

[dick0236]

It has not been very long since your surgery and your introduction to warfarin. You are still in the "dosage adjusting" time period and a 4.9 might not be too unusual except it is a significant change from the 3.3 in only one weeks time. Your manager may, or may not, reduce your dosage a little until your next test. If your next test is still that high you will want to reduce your weekly dosage 10-15%.

I agree with Andy on the alcohol. A few drinks will not cause problems. Hard drinking may very well cause problems. Been there, done that.

Veges and products containing vit K have never been a problem for me and they are a big part of my diet. The key is consistency, but you need not be paranoid in your eating habit. I eat them when I want them without giving INR levels much thought. As has been said on many posts, you would have to binge for vit K to have much effect on INR.

I have never been able to find a OTC pain killer other than tylenol, or its generic for everyday pain meds.

 

[Ross]

First off, the diet! Throw that vit k foods list out the window. It will do nothing but promote a yo yo INR. Eat as you normally have in the past, including spinach or whatever else you love that's high in vit k. Your dose will be adjusted for that diet. Our saying here is dose the diet, don't diet the dose. Without more information such as your dose, other meds and such, it's hard to say, but I'm thinking that 4.9 was an erroneous test.

 

[Maryka]

Ross, it is easy for you to say to throw the vitamin k list out of the window, because, as a home-tester, you can easily check. For those of us who must make an appointment, drive to the tesing office, wait in line, then pay $$$ because the insurance does not cover much of it, it is a really big deal. I have found the vitamin k list VERY helpful because I do not have time and money for frequent testing related bother. I have found my diet and I keep to it, even if it means peeling lettuce off of sandwiches when I am eating out. It works for me.

 

[Cris N]

Ross, it is easy for you to say to throw the vitamin k list out of the window, because, as a home-tester, you can easily check. For those of us who must make an appointment, drive to the tesing office, wait in line, then pay $$$ because the insurance does not cover much of it, it is a really big deal. I have found the vitamin k list VERY helpful because I do not have time and money for frequent testing related bother. I have found my diet and I keep to it, even if it means peeling lettuce off of sandwiches when I am eating out. It works for me.

I understand your concern about the time/money for testing, but I do think you're being overly cautious about vit k. Peeling lettuce off sandwiches deprives your body of needed nutrients. If I were in your shoes I think I would gradually up my overall vit k amount (I take Vit K tablets) so that your dosage gets adjusted to allow for higher vit k foods... so many of them are the really healthy ones!

 

[Ross]

First, on alcohol, I've been told several times now (by several diff. docs) that it's ok to have an occasional 2-3 drinks in a given night, but if you get beyond that it gets dangerous. My understanding of the danger is that alcohol further thins your blood. And if you're already anti-coagulated like we are, you start running the risk of things like internal bleeding with more than 2-3 drinks. And, if you were to happen to get cut it could bleed pretty bad. I think there's some other risk factors w/ more alcohol than 2-3 drinks (something with the stomach - like ulcers?).

:frown2:You mean I can't have 4 bloody mary's or a 1/2 a fifth of Vodka?:frown2:

For most people, alcohol does nothing to their INR. Others, it rises, others it lowers. All you can do is have a few, then test and see which category your in. The big deal with alcohol is eating a hole in your stomach. If you get an active bleed going from an ulcer, your in serious danger.

 

[Ross]

Ross, it is easy for you to say to throw the vitamin k list out of the window, because, as a home-tester, you can easily check. For those of us who must make an appointment, drive to the testing office, wait in line, then pay $$$ because the insurance does not cover much of it, it is a really big deal. I have found the vitamin k list VERY helpful because I do not have time and money for frequent testing related bother. I have found my diet and I keep to it, even if it means peeling lettuce off of sandwiches when I am eating out. It works for me.

Your welcome to do as you wish, but your actually dieting your dose and depriving yourself of much needed nutrients. You simply need to eat as much as you normally do all the time and have the dose adjusted for that diet. Vit K in food is a minuscule part of INR management. You would really have to pig out on something high in vit K to even dent your INR.

When I first started Coumadin, I did all the things your doing and all it did was frustrate me and drive me nuts with bouncing INR's. I bought the Coumadin cook book, thinking I'd be the perfect Coumadin complaint patient. It didn't take me long to scrap that whole idea and just eat what I wanted to eat. I now enjoy, spinach, broccoli, brussel sprouts and many other high content vit K foods and my INR is in range almost always. Please note that I do not test every time I eat high Vit K foods. I test once a week and once a week only unless I've had a medication change that I know will affect INR.

Popeye says, eats your spinach:

 

[mecretired]

Thanks for all the advice/info. I'm feeling a bit better about it all. The only thing that I changed as far as diet, etc. during the week prior to 4.9 was--I had 2 1/2 glasses of wine Sunday pm and since I went off pain meds, I took some Tylenol probably 2-3 times during the week. When the lady from the coumadin clinic called to give me my INR of 4.9, she specifically asked if I had taken a lot of Tylenol. My dosage had been 37.5mg for 3 wks straight, then when I had the 4.9 reading the dosage was reduced to 27.5 mg. I will have my INR checked again on Monday. I'm not sure when I will go to self testing. I have an appt for my followup on 6/11. I assume we will talk about it then. I was told that my doctor's office will "give me" a tester--for a charge? --not sure. I do know that my insurance does not cover them. When you self test, how often do you usually check your INR? Thanks again. It really does make me feel so much better knowing that I have all of you "out there" to talk with.

 

[Ross]

They dropped your dose way too much, so plan on being too low. I'm betting that 4.9 was a bad test result. We can worry about that after your next test.

Anyhow, I would file an appeal with the insurance company to get it covered. It's worth a shot and if you need them, I can get you all sorts of documentation indicating that it would be better for you and cheaper for them, in the long run.

As far as how often you test, for now, weekly. Once your rock solid stable, you'll be moved to 2 or 4 weeks. Personally, I believe in testing at least every 2 weeks. If I go 4, my INR will certainly creep out of range one way or the other.

 

[dick0236]

I agree with Ross that the 4.9 was an error reading and that the change from 37.5 to 27.5 will drop your INR too much:thumbd:......but who knows:thumbup:...and its not a big deal. Come back and post your numbers after the next one or two tests.

I test every two weeks unless I get a test that requires a warfarin adjustment....then its one week after the adjustment.

I think "pealing lettuce off a sandwich" is unecessary.:smile2:

 

[lance]

I took some Tylenol probably 2-3 times during the week. When the lady from the coumadin clinic called to give me my INR of 4.9, she specifically asked if I had taken a lot of Tylenol.

Recently I took the recommended dose of Tylenol for pain relief and I'm absolutely certain, without doubt, that it caused an escalation in my INR. When I Googled for Tylenol warfarin interactions I found a site I thought reliable advising up to 1400 mgs per day would not affect INR. Over 1400 would. Taking Tylenol according to package directions exceeds 1400 mgs. a day. Whenever I take Tylenol I keep that in mind.

 

[Cris N]

I have to toss out one more thought on peeling the lettuce off a sandwich. The average iceberg lettuce leaf (probably twice as much as what would usually go on a sandwich) has only about 1/4 the amount of vit k as a pear. The average pear has only 7.5 mcg vit k. The lettuce - 1.8

 

[Bill B]

I am a newby to Warfarin. I had surgery on May 3, 2010 to replace my ascending aorta and aortic valve with an SJM grafted valve. Right now the "coumadin clinic" associated with my doctor's office is monitoring my dosage. I go into the lab for INR checking once per week. The clinic then calls to tell me what my dosage should be for the following week. My INR is supposed to be between 2.5 and 3.5. I had been at 3.3 for 2 wks then it went to 4.9. I really don't know what caused the difference but have lots of questions. I have a long list of foods that contain Vit K and a long list of medications that will thin the blood. One of my questions is "Can I have a serving of spinach (or any of the other foods on the list) one evening/wk without worrying about changing the dosage?" I really don't want to have to eat a serving every day/I would rather give up all those foods.

Who said you need a serving every day? The best thing is to just be consistent. Eating spinach (or equivalent) once a week is fine, as long as it regular. In fact, I don't think it's good to avoid vitmain K altogther, especially if you didn't before. The voluminous lists often have things that are not really loaded with vitmain K. I just go by if it's dark green (there are only a few exceptions). For instance, iceberg lettuce does not have very much K in it. Darker greens do. Some people who are very sensitive to warfarin (I appear to be one of them at 1.5mg/day) probably should take in more vitamin K as it seems to reduce unstable response. My INR has bounced around more than it should. I was avoiding all greens. I now take in some greens, although not everyday.

Also, what OTC meds do you take for headaches/muscle aches, etc.?

Tylenol. It should not have any effect in the amount you take.

Can you drink any amount of alcohol without it affecting your INR? Prior to surgery, my surgeon told me it wouldn't be a problem for my husband and I to share an occasional bottle of wine. The more I read, the more discouraged I get. So, HELP?:confused2:

Don't get discouraged. It should not be that hard. Moderate amounts of just about anything is OK. Consistency is best. I agree that with a 4.9, you should have had a quick verification test.

 

[Ross]

ACETAMINOPHEN INTERACTIONS WITH WARFARIN

Brand Names: ACETAMINOPHEN - Tylenol, Feverall, Acephen, Neopap, Apacet, Children's Dynafed Jr. Genapap, Maranox, Mapap, Panadol, Tempra, Aceta, Aspirin Free Pain Relief, Genebs, Meda, Tapanol, Aspirin Free Anacin Maximum Strength, Extra Strength Dynafed E.X. Redutemp Dapacin, Infants' Pain Reliever, Silapap, Ridenol, Oraphen PD, Children's Pain Reliever, Halenol, Liquiprin, Capital with Codeine, Tylenol with Codeine, Acetaminophen with Codeine, Aceta with Codeine, Fioricet with Codeine, Lortab, Zydone, Hydrocodone with Acetaminophen, Bancap HC, Ceta-Plus, Co-Gesic, Duocet, Dolocet, Hydrocet, Hydrogesic, Hydrophen, Margesic - H, Lorcet, Anexsia, Panacet, Stagesic, T-Gesic, Vicodin, Norco, DHC Plus, Acetaminophen with Oxycodone, Percocet, Roxicet, Roxilox, Tylox, Propoxyphene Napsylate with Acetaminophen, Darvocet N, Propacet 100, Wygesic, and many other brands. There are so many that they could not all be listed here. If you are taking warfarin, you should read the label of any pain relief medication to determine if it contains acetaminophen. If you are unsure, purchase the product at a pharmacy where you can have the pharmacist check the label for you.
Acetaminophen is the safest pain reliever to take with warfarin. It does not cause bleeding of the lining of the gastrointestinal tract as many other pain relievers do.
However, Hylek et al. found that if a person takes more than 26 regular- strength (325 mg each) or 19 extra-strength (500 mg each) over one week, the International Normalized Ratio (INR) may be raised. This will increase the chance of a person bleeding.
Two articles have added insight as to how this may occur. Lehman hypothesized that various enzymes in the liver may be involved in different patients. These have to do with metabolizing the two forms of warfarin and acetaminophen. These may come into play with varying conditions such as in older patients, those with atrial fibrillation and congestive heart failure. This theory could account for why some people are affected and some are not.
Whyte et al. reported their observations in a regional toxicology center. They found that a small rise in the INR is common after acetaminophen poisoning without liver injury. This appears to be caused by inhibition of clotting factor VII. This would account for the interaction between acetaminophen and warfarin.
My opinion is that the theories of Lehman and Whyte do not contradict each other. They are probably both involved in explaining what Hylek observed.
Addendum: Many of you may be familiar with other websites and a story that ran on CNN stating that acetaminophen and warfarin is a harmful combination. Since I wrote this page, I have had an opportunity to speak with Dr. Hylek. She regretted giving the interview, which was edited to make it appear that she was stating that this combination was harmful.
References:
Hylek EM et al. Acetaminophen and other risk factors for excessive warfarin anticoagulation. JAMA 1998;279:657-662.
Lehmann DE. Enzymatic shunting: resolving the acetaminophen-warfarin controversy. Pharmacotherapy 2000; 20:1464-1468.
Whyte IM et al. Acetaminophen causes an increased International Normalized Ratio by reducing functional factor VII. Ther Drug Monit 2000;742-748.
Remember that nothing on these pages should encourage you to start or stop taking any medication. You should consult with your physician. Many interacting medications can be safely taken if the INR is monitored frequently. Stopping an interacting medication can upset the balance between warfarin and other medications.

 

[jax]

I normally eat what I want and don't worry about my inr much. That includes veggies with vitamin K. I was the same before I got my home testing machine. My inr will fluctuate a little but normally too much. Yes going to the hospital for testing is a pain but for me I didn't let it affect my diet to restrict vitamin K. Some things you just learn over time after surgery. I just figured I had enough to worry about without worrying about how many veggies with vitamin K I was eating. I feel ross is right on the mark with this one. Dose the diet not diet the dose. The dose can always be changed. Why should we stop eating the things we love. Yes I am more concientous on what I eat but I concern myself more on sodium levels in food more than anything. I also choose leaner cuts in meat but seldom worry about my vitamin K intake. And my inr has not been out of control unless there has been a drastic change in my diet which I keep things pretty normal.

 

[Ross]

I normally eat what I want and don't worry about my inr much. That includes veggies with vitamin K. I was the same before I got my home testing machine. My inr will fluctuate a little but normally too much. Yes going to the hospital for testing is a pain but for me I didn't let it affect my diet to restrict vitamin K. Some things you just learn over time after surgery. I just figured I had enough to worry about without worrying about how many veggies with vitamin K I was eating. I feel ross is right on the mark with this one. Dose the diet not diet the dose. The dose can always be changed. Why should we stop eating the things we love. Yes I am more concientous on what I eat but I concern myself more on sodium levels in food more than anything. I also choose leaner cuts in meat but seldom worry about my vitamin K intake. And my inr has not been out of control unless there has been a drastic change in my diet which I keep things pretty normal.

Most people, including myself, started out dieting the dose because we were paranoid of what might happen if we didn't. I was leaving my oil set in the sunlight to kill the Vit K, not eating greens of any sort and just miserable. One day, I threw the whole idea out the window, put the Coumadin cookbook away and went back to my old ways of eating. Took me about 2 weeks to get my INR suited to my diet and I've been fine ever since. New meds are about all that throw me off now.

Most people will go back to their old eating habits in time. Life is boring when you don't eat what you want and your body needs those nutrients anyhow.

 

[mecretired]

I just got my new INR from lab yesterday and it is 2.7. That is down from 4.9 with a change of warfarin of 37.5 mg/wk to 27.5 mg/wk. So I'm thinking that the 4.9 was not an error but I still don't know what caused it. As I said earlier, I had 2 glasses of wine on Sunday. I took some extra strength Tylenol (500mg), but never more than 2 on 1 day--and I did that only 2 or 3 times during the week. I started back on my calcium +vit D that week but the lady from the Coumadin Clinic said that, if anything, that would lower the INR. I am on 32.5 mg this week. Thanks again for all of the input. I was really down about it all and you helped so much. Right now, I'm just not going to worry about it--just try to eat, drink, or whatever, within reason.

 

[Ross]

Now, why did they increase your dose when your in range? I see the yo yo effect coming up. They should leave you alone for a full week and test one more time at your 27.5 dose.