How about testing daily for 6 months??

[DrAllan]

This is a message for those of you having difficulty keeping steady on Coumadin either through your own efforts or a medical professional. The frequency of testing may have nothing to do with it. For those of you who have rock steady INRs, I am extremely jealous.

Yes, I am a physician. No, I never dosed Coumadin until I started about 18 months ago. No, I can't keep my own INR stable. Yes, i have self studied about 150 hours of literature and driven my consulting hematlogists crazy. The once a week lab draw were always a pain and variable. I started home testing at three-day intervals. About six months ago, one of my physician colleagues made a stab in his office on Coagucheck, but gave it up for lack of patient interest. He gave me enough supplies, that I have been testing DAILY for the past six months. My INRs are still variable. I have tried every possible combination of regimes. Stay on the same dose regardless of INR, still fluctuates. Adjust the dosage based on an estimate of K intake, still fluctuations. I even tried total Slimfast diet for two weeks to strictly control my K, still fluctuations. Sit in front of the computer for a week, still fluctuation. Paint ceilings and walls of 6 bedrooms and three bathrooms, still fluctuation.

So, for me adjusting INR is a study in frustration. Yes my range is 2.5-3.5 and I can stay between 2.1-5.1. The best example of fluctuations that prior to a surgical procedure were the physician was comfortable with 2.0-3.0, I was between 2.1-3.3 for a solid week. The day of surgery I was 1.5!!!.

I will be out of the country for a week and will not be able to reply to any questions, although there are no answers.

 

[Nan]

Hi,
first of all, I hope you have a good trip!! And are not worrying about your INR!

And secondly, even though you are frustrated with your INR, keeping it between 2.1 and 5.1 is not so awful...at least it is above 2 (except for just before your surgery).

IMHO so long as you are not having bleeding episodes when it is in the 4-5 range, you are doing OK. How often is it over 4?

Since you are testing every day, you are catching every possible variation. I would bet that a lot of us have INR's with a wider range than our 2-3 or 2.5-3.5 window.

Let's see what Al says.....

Take care,

 

[Ross]

I guess I need a definition of fluctuate. Are we talking mild changes, which I don't think so, but having wild swings instead? Testing daily isn't going resolve much. I hope your not changing doses everyday.

 

[DrAllan]

Ross,

thank you for the comment. I thought my original post was clear about the metthods I have tried. An example of fluctuation is 2.2;4.7;2.5. I maintain my figures on a database program that calculates the total dose for the preceding 5 and 7 days as well as the avrage for those time periods. Any dosage changes I make arecalculated to maintain either a steady weekly intake of coumadin or reflect a pertial (NOT SUDDEN) 10-20% change in the therapy. I think that the regimes some others folllow of of once or twice a week having a different dose than the other 5 days to "average" the weekly dose is mathematical and pharmacologically without scientific merit. For most, the bodies chemsirty evens this out. In my case, I suspect that my metabolism does not do this. Any other thoughts will be interesting to ponder.

 

[davidfortune]

Ever thought about taking a supplement with high vitamin K included? This will require a higher coumadin dose to get INR therapeutic but may stabilize it since any dietary and exercise based changes are then a very small percentage change in daily K intake.

One other member posted he takes a multi-vitamin supplement with 80mg of Vitamin K (from CVS or Walgreens I believe). Obviously his daily coumadin requirements are higher to keep his INR therapeutic but he indicated that his INR is very stable. The thought seemed logical to me.

 

[Ross]

You just have to be all complicated huh Doc. I've heard and seen swings like this, but I'm letting this one go for Al Lodwick to take a stab at.

 

[Ross]

Ever thought about taking a supplement with high vitamin K included? This will require a higher coumadin dose to get INR therapeutic but may stabilize it since any dietary and exercise based changes are then a very small percentage change in daily K intake.

One other member posted he takes a multi-vitamin supplement with 80mg of Vitamin K (from CVS or Walgreens I believe). Obviously his daily coumadin requirements are higher to keep his INR therapeutic but he indicated that his INR is very stable. The thought seemed logical to me.

David that is what he was attempting to accomplish with the Slim Fast. I think he's just one of the few people that are extremely hard to stabilze. Certainly beyond anything I can recommend.

 

[davidfortune]

Yeah Ross but lowering your overall vitamin K intake will result in a LOWERED required coumadin intake. Seems to me - if your coumadin requirements are LOW - ANY small change in vitamin K or exercise would be a much larger PERCENTAGE of your total and therefore a much larger impact on your INR.

Seems to me (follow the logic) - Increase your daily vitamin K AND (PLEASE EVERYONE READ THE "AND" HERE and don't send me flaming emails) increase your daily coumadin to meet the increased K intake. Therefore any OTHER variable that is affecting your INR will be a much lower PERCENTAGE of the total and therefore have a SMALLER impact on your INR. This requires a coordinated increase in coumadin to prevent the INR from dropping sub-therapeutic as the vitamin K is increased significantly. (so maybe you half the multi-vitamin for the first week and increase the coumadin and then take the whole multi-vitamin the second week if the INR stayed in range and increase your coumadin again the second week since you now take the whole multi-vitamin).

The supplement route seems logical to me because this is based on a very stable, predictable, measurable vitamin K intake (i.e. 80 mg which is 100% RDA). i.e. you KNOW exactly what the K intake will be and it will be EXACTLY the same everyday. This should make everything else of lesser consequence.

Doesn't that make sense?

 

[Ross]

Yes it makes sense theoretically, but you still have to deal with the K that the body makes on it's own or lack of it and that in foods. It should make it more stabile, but I'll bet it just doesn't work for everyone. Trial and error is usually how we find out for sure.

 

[Rain]

Has the dog been getting in your flower bed?

Has the dog been getting in your flower bed?

Dr. Allan,

Thank you for this post. There are a lot more of us like you out here than you would think. This forum just hasn't been a real friendly environment to discuss it.

I?ve pondered the same thing David posted about. For that reason I am curious as to how much coumadin you take per day. My dose is only 3 ½ four days, 4 three days a week.

It would be interesting to compare notes with others who have a hard time with their INR regulation.

Have a great trip!!

 

[Guest]

I am happy with patients whose INRs stay within the range that Dr. Allan's do. There is little risk of bleeding with INRs below 5. Also little risk of clotting with INRs about 2.0 or so. I don't think that his INRs are out control. I would probably not have adjusted a warfarin dose fro any of them. I'd probably only test him every 4 to 6 weeks. I'd put big money that the outcome 5 to 10 years down the road would be the same as testing daily.

Trying to stay strictly in range is like trying to drive cross-country keeping the gas tank exactly half full. It can be done - but why go to all the trouble?

 

[Karlynn]

Didn't see this post before, for some (spacy) reason. I think that with any medication, there is going to be a subset of people who are more difficult to regulate than others. Warfarin is not the exception. Unfortunately, the problem warfarin users come up against is that many times we find that those people who describe themselves as hard to control might be dealing with INR management that is incorrect, thus causing their INR's to flucuate more than they should. Looks like DrAllan might be one of the few "true" hard to manage cases.

One of the problems we see is when Coumadin managers adhere strictly to the patients range and make changes for INR's even a few points outside the range. We've had members here being told to hold a dose for a 3.7 INR. Then their next test they are dealing with a 1.5.

I've been on Coumadin for 15 years. Most of my knowledge on it has been aquired in the last 5. Al, and this site, have been the biggest source of that information.

I used to be considered hard to manage. It's the reason insurance allowed for my home testing 4 years ago. I rarely have an INR within my 2.5 - 3.5 range 3 weeks in a row. Part of that is because I'm on a dose to keep me to the higher side of my range. So going into the 4's isn't uncommon for me and I rarely make changes.

I've said many times here - the lack of correct warfarin knowledge within the medical community itself by be a very valid reason not to choose mechanical when selecting a valve. I find that rather sad because I do think that for some, it may be the best choice.

Since I haven't made a concerted effort to work out this summer, my dose has decreased. But I didn't do that until I had 4 consecutive weeks in the 4's. I know that someone else might have done it differently.

I don't bruise any differently at 4.7 than I do at 3.0 and that's not a lot.

I know Rain has issues with her Coumadin and can tell when she's too high by the bruising. I'd be interested to find out, if it's possible, why some people have those issues. Is it body chemistry? Is it the components specific to their own blood?

 

[Gnusgal]

I know Rain has issues with her Coumadin and can tell when she's too high by the bruising. I'd be interested to find out, if it's possible, why some people have those issues. Is it body chemistry? Is it the components specific to their own blood?

I also can tell when I'm high by an increase in bruising, as well as bloody noses. I can also get more petechiae when I'm on the high side. Normally I take this to mean I should eat some more greens and don't do anything to my dose. Recently, however, I've been too high for several weeks, and adjusted my does down... Still too high. The best I can figure is that the new meds I'm on, plus the bronchitus I've had for the last two weeks, is what is contributing to the high INR. Yes, I look like I've been abused with all the bruises, but I'd rather have those than a stroke... I'm hesitant to reduce my dose any more than I already have for fear that it will drop like a rock when I finally get better.

I don't know why some people bruise more when they are too high and others don't. I assumed everyone did, but apparently that was a wrong assumption. For me, the slightest little bump can produce a bruise of landmark proportions. I actually had to tell someone I ran into a doorknob, because it was true!

 

[Karlynn]

I know Rain has issues with her Coumadin and can tell when she's too high by the bruising. I'd be interested to find out, if it's possible, why some people have those issues. Is it body chemistry? Is it the components specific to their own blood?

Clarification. I reread this quote in Nicki's post and realized it sounded like I was questioning whether it was possible that people could tell if they were high by bruising. What I was wondering was if it was possible to isolate why some people seem to have more reaction to higher INR's than others. Does it have to do with their own blood chemistry or some other such thing. I wasn't intimating that I didn't believe them.

 

[Gnusgal]

Clarification. I reread this quote in Nicki's post and realized it sounded like I was questioning whether it was possible that people could tell if they were high by bruising. What I was wondering was if it was possible to isolate why some people seem to have more reaction to higher INR's than others. Does it have to do with their own blood chemistry or some other such thing. I wasn't intimating that I didn't believe them.

I didn't read your original post as saying that it wasn't possible to tell you were running high from signs like bruising. I was just telling about my particular situation. No worries.

 

[Dustin]

DrAllan,

Have you looked into other anticoagulants such a Fenprocoumon, which has a longer half-life than that of warfarin? Over here, patients that cannot stabilize their INRs on Acenocoumarol are switched to Fenprocoumon, often leading to much more stable INRs, though this need not always be the case.

Half-life short --> long : Acenocoumarol --> Warfarin --> Fenprocoumon.