How often do you test INR?
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normofthenorth
Well-known member
I'm just a visiting member, I hope -- I'll find out around March 1, when I'm scheduled to come off it, as long as I don't have A-Fib or another condition that indicates it. I've searched for clinics that used the Coaguchek-type machines, but the ones in Toronto I've found aren't nearly as close as my GP's clinic, where they do the vein draw thing. My GP just replaced my expired 2x/week prescription for INR testing with one for BI-weekly testing, which I told her wasn't often enough, if I got out of range. We compromised on WEEKLY, then the next day (when she was phoning me to tell me my slightly out-of-range test results) she told me to come back for re-testing 4 days after my previous test! 
That test was identically slightly out-of-range, so she phoned me and told me that she'd left the authorization for 2x/week testing at the reception desk!
It's not as if I actually got to the lab 2x/week for testing, during the first month (especially with Christmas and NY), but it makes sense to have it available when appropriate. Testing 1/wk or 1/2 weeks makes perfect sense once you've got it stabilized and figured out. I'm sure some of the "old-timers" test even less frequently.
Home testing seems to make perfect sense too, but probably not for us visitors. I'm hoping that Ontario will change the laws soon to allow pharmacists to check INRs with a Coaguchek.
That test was identically slightly out-of-range, so she phoned me and told me that she'd left the authorization for 2x/week testing at the reception desk! It's not as if I actually got to the lab 2x/week for testing, during the first month (especially with Christmas and NY), but it makes sense to have it available when appropriate. Testing 1/wk or 1/2 weeks makes perfect sense once you've got it stabilized and figured out. I'm sure some of the "old-timers" test even less frequently.
Home testing seems to make perfect sense too, but probably not for us visitors. I'm hoping that Ontario will change the laws soon to allow pharmacists to check INRs with a Coaguchek.
ALCapshaw2
Well-known member
It takes 3 or 4 days for Coumadin / Warfarin to become fully metabolized so testing more often than every 4 days when you start your anticoagulation is NOT wise. Changing Dosing before the last change has become fully effective often leads to the dreaded Roller-Coaster Effect and is a sign that the manager is poorly trained, does not understand how Coumadin works, or Over-Reacts to out of range results.
Patients are often started on 5 mg and tested in a few days to see how they are progressing.
There can be High Metabolizers who need higher doses, and Low Metabolizers who need lower doses so it takes a bit of 'Trial and Error' testing / dosing to get you headed in the right direction. There is a genetic test that can tell which category you fit into but it is EXPENSIVE and most Doctors / clinics do not use it.
Once you become more stable, testing intervals will be increased to 1 week, then 2 weeks, and eventually to 4 weeks apart if you have been stable for several tests.
Good Luck with BCBS! Their rules (and finding knowledgable personel) vary GREATLY from state to state. That said, give it a try, but you may have to pester them until you can find someone who actually knows what anticoagulation is. Then you have to hope that BCBS in your state has decided to embrace Home Testing. Not all have, but it's worth trying.
Good Luck!
'AL Capshaw'
Patients are often started on 5 mg and tested in a few days to see how they are progressing.
There can be High Metabolizers who need higher doses, and Low Metabolizers who need lower doses so it takes a bit of 'Trial and Error' testing / dosing to get you headed in the right direction. There is a genetic test that can tell which category you fit into but it is EXPENSIVE and most Doctors / clinics do not use it.
Once you become more stable, testing intervals will be increased to 1 week, then 2 weeks, and eventually to 4 weeks apart if you have been stable for several tests.
Good Luck with BCBS! Their rules (and finding knowledgable personel) vary GREATLY from state to state. That said, give it a try, but you may have to pester them until you can find someone who actually knows what anticoagulation is. Then you have to hope that BCBS in your state has decided to embrace Home Testing. Not all have, but it's worth trying.
Good Luck!
'AL Capshaw'
Philip B
Well-known member
Monitoring Questions?
Monitoring Questions?
Many insurance companies cover the costs of monitors and many refuse to cover these costs. Mine initially refused to cover the purchase of my monitor. After purchasing a monitor on my own, I fought a six month battle to win reimbursement. Others have reported fewer issues than I encountered; I had lousy insurance.
I test at least once a week; sometimes I test a couple of times depending on my activity level. Other members report testing less frequently (every two or three weeks).
-Philip
Monitoring Questions?
Many insurance companies cover the costs of monitors and many refuse to cover these costs. Mine initially refused to cover the purchase of my monitor. After purchasing a monitor on my own, I fought a six month battle to win reimbursement. Others have reported fewer issues than I encountered; I had lousy insurance.
I test at least once a week; sometimes I test a couple of times depending on my activity level. Other members report testing less frequently (every two or three weeks).
-Philip
I test weekly, but to me that's sorta overkill especially since I'm in range. I'll be going to bi-monthly testing as soon as I talk to my cardio. There is no uniformity among insurance companies, so that's a hard one to answer.
My "normal" time, if I go to an INR clinic or doctors office is one month, more frequent if the INR is out of range. I have tried home testing, and tested bi-weekly during that time. I found my hassle with the program servicing provider, not the insurer, to be the problem.
I have my own meter and, for now, a good supply of strips, so I test weekly. In the past, because my INR when it WAS occasionally taken, was pretty stable. Although my weekly results vary slightly from week to week, I am still almost always within range.
For myself, oddly enough, the frequency of testing depends a bit on the meter. When all I had was a ProTime or ProTime 3, I tested every two or three weeks. Now that I have an InRatio (and strips), I'm testing weekly. I think it's probably because the InRatio is less of a hassle -- I don't have to remember to take the strip out of the refrigerator to warm up, I don't have to work to get enough blood transferred into a little cup on the lancing device, etc.
The answer, though, is probably what my last cardiologist wanted -- test every two weeks once the INR is stable. If it's out of range, or if activities or diet change significantly, testing more often may be wise.
One thing to consider: If the cost of testing and the inconvenience of going to a lab or clinic for a blood draw are no longer factors in deciding how often to test, wouldn't more frequent testing be preferred?
For myself, oddly enough, the frequency of testing depends a bit on the meter. When all I had was a ProTime or ProTime 3, I tested every two or three weeks. Now that I have an InRatio (and strips), I'm testing weekly. I think it's probably because the InRatio is less of a hassle -- I don't have to remember to take the strip out of the refrigerator to warm up, I don't have to work to get enough blood transferred into a little cup on the lancing device, etc.
The answer, though, is probably what my last cardiologist wanted -- test every two weeks once the INR is stable. If it's out of range, or if activities or diet change significantly, testing more often may be wise.
One thing to consider: If the cost of testing and the inconvenience of going to a lab or clinic for a blood draw are no longer factors in deciding how often to test, wouldn't more frequent testing be preferred?
Herb M
Well-known member
I usually have a blood draw every 5 or 6 weeks. If I am out of range and make a doseage adjustment, I will check in a week or two.
Sarah_Louise
Well-known member
When i was on warfarin, and i had an INR tsting machine at at home, depending of how my level was depended on how often i tested it, as instructed by by heamatologist & cardiac liason nurses...if my level was ok i would test on a monday for the week, then on a friday for the week end, but if my level wasn't right, which seemed to be the case nearly all of the time, i would test every other day,
Good luck with it xxx
Good luck with it
xxxALCapshaw2
Well-known member
When i was on warfarin, and i had an INR tsting machine at at home, depending of how my level was depended on how often i tested it, as instructed by by heamatologist & cardiac liason nurses...if my level was ok i would test on a monday for the week, then on a friday for the week end, but if my level wasn't right, which seemed to be the case nearly all of the time, i would test every other day,
Good luck with it
If you were changing your dose every other day, it's NO Wonder your INR was Never Right!
It would appear that your anticoagulation managers do NOT understand how Coumadin / Warfarin works
and do NOT know how to manage it properly. I suspect their training is Way Out of Date.
The New Guidelines in use in the USA work quite well for most patients.
Coumadin / Warfarin takes 3 or 4 days to become fully metabolized.
If you change your dosing 2 days after your last change,
that change is NOT fully accounted for in your next change.
If you change again after another 2 days, your changes are 'stacking up'
and you will Bounce Around FOREVER until you stop changing doses so often.
When you change your dosing, most Clinics wait 2 Weeks before testing again.
Home Testers whose INR is 'moving around' typically test ONCE per week,
then every 2 to 4 weeks when stable.
I used to test every 2 or 3 weeks - sometimes longer - when I had a certain meter and a limited supply of strips. For me, 25 strips would last nearly a year with testing every other week.
Now, I'm fortunate enough to have a good supply of strips and a meter I actually enjoy using. I'm able to test once a week - although it's probably not really necessary. My INRs Do vary slightly sometimes from week to week - but I don't stress over the variations as long as I'm in range. I've gotten used to NOT overreacting to a 2.7 one week and a 3.1 the next. It all seems to stay within range with unchanged doses.
(There was a time last year when my INRs began running high - I adjusted my weekly dose from 52 to 49 and all seems to be pretty well).
I'm not sure if, after going a long time between tests a few years ago, I'd again be comfortable with testing every month or two (or more), but the THEORY that IF your dosage is consistent, and your INRs are stable, THEN you can go for longer periods without testing may be valid - but I don't think I'd want to test it again.
Now, I'm fortunate enough to have a good supply of strips and a meter I actually enjoy using. I'm able to test once a week - although it's probably not really necessary. My INRs Do vary slightly sometimes from week to week - but I don't stress over the variations as long as I'm in range. I've gotten used to NOT overreacting to a 2.7 one week and a 3.1 the next. It all seems to stay within range with unchanged doses.
(There was a time last year when my INRs began running high - I adjusted my weekly dose from 52 to 49 and all seems to be pretty well).
I'm not sure if, after going a long time between tests a few years ago, I'd again be comfortable with testing every month or two (or more), but the THEORY that IF your dosage is consistent, and your INRs are stable, THEN you can go for longer periods without testing may be valid - but I don't think I'd want to test it again.
Sarah_Louise
Well-known member
Noooo....i would test my INR every other day BUT my dosage would NOT fluxuate (i think thats how u spell it lol) what ever dose i was on, i would be on it at least 3/4 day's before it changed, and if it was changed it would only decrease/increase .5/1/1.5mg each time....
To be honest my heamatologist and cardiolgist and nurses ect are fantastic and im sure they DO know everything they need to know about anticoagulation, my heamatologist and cardiologist are one of the top in the country, so they must have had the right training.....
The plan was to test once a week/month ect but i was never stable anough to get onto that, so they where ensuring my saftey by checking the INR, because if one day my INR was 2.4 and i was on 5mg of warfarin then the next day it was 7.2 and i didn't check it, it could have proved particualary dangerous for me when moving about around a school of 1800 people......There was at one point my INR hit 6.8 and they stopped warfarin for 2 days, and instead of going down it went up to 7.1, so non again and this carried on, i.e. increasing with having NO warfarin, hence the reason i was testing every other day, at the time though they admitted me in hospital becuase it was out of control.
Warfarin and me just don't get on, thats the conclusion EVERYONE came to, my two heamatologists, my cardiologist, cardiac liason nurses, GP, parents and ME, so now im on heparin injections full time and there great
xxALCapshaw2
Well-known member
Noooo....i would test my INR every other day BUT my dosage would NOT fluxuate (i think thats how u spell it lol) what ever dose i was on, i would be on it at least 3/4 day's before it changed, and if it was changed it would only decrease/increase .5/1/1.5mg each time....
To be honest my heamatologist and cardiolgist and nurses ect are fantastic and im sure they DO know everything they need to know about anticoagulation, my heamatologist and cardiologist are one of the top in the country, so they must have had the right training.....
The plan was to test once a week/month ect but i was never stable anough to get onto that, so they where ensuring my saftey by checking the INR, because if one day my INR was 2.4 and i was on 5mg of warfarin then the next day it was 7.2 and i didn't check it, it could have proved particualary dangerous for me when moving about around a school of 1800 people......There was at one point my INR hit 6.8 and they stopped warfarin for 2 days, and instead of going down it went up to 7.1, so non again and this carried on, i.e. increasing with having NO warfarin, hence the reason i was testing every other day, at the time though they admitted me in hospital becuase it was out of control.
Warfarin and me just don't get on, thats the conclusion EVERYONE came to, my two heamatologists, my cardiologist, cardiac liason nurses, GP, parents and ME, so now im on heparin injections full time and there great
Do you mean that your DAILY dose is changed by 0.5 / 1.0 / 1.5?
or do you mean that your WEEKLY dose is changed by 0.5 / 1.0 / 1.5?
Even changing every 3 or 4 days is TOO SOON IMO.
FWIW, when I am slightly out of range, a 1 mg change in my WEEKLY dose brings me right back where I need to be.
Most likely, changing by 1 mg / DAY or even 0.5 mg/DAY would swing me out the opposite side.
I also eat something Green (i.e. Vitamin K) daily.
Studies have Proven that a consistent level of Vitamin K intake results in a More Stable INR than trying to completely avoid any vitamin K.
NO vitamin K is like walking into a Dark Room.
Then consuming ANY vitamin K is like turning on a light.
HUGE Difference.
Consistent Vitamin K is like walking into a room with a 50 watt light turned on.
Consuming More Vitamin K would be like changing from a 50 watt light to a 100 watt light.
SMALL Difference.
Sarah_Louise
Well-known member
WEEKLY dose
But like i have said thankfully i don't have this bother any more,
Im on heprin which means 1 injection each day and a factor 10 blood test every few weeks, thats working for me so im happy lol, i've gave up my fight when it comes to warfarin lmao
xxxALCapshaw2
Well-known member
WEEKLY dose
But like i have said thankfully i don't have this bother any more,
Im on heprin which means 1 injection each day and a factor 10 blood test every few weeks, thats working for me so im happy lol, i've gave up my fight when it comes to warfarin lmao
Do you mean an Injection of Low Molecular Weight Heparin (a.k.a. Lovenox)?
In the USA, Lovenox injections are prescribed for TWICE a day (i.e. every 12 hours)
because it has a Very Short Half Life.
List Price for a single Lovenox injection at my Pharmacy is $107.00 U.S.
Generic Warfarin costs $4 for 30 tablets or $10 for 90 tablets (roughly 11 cents per pill)
Yes, I have heard that there are some patients who have difficulty reaching a stable INR but that is pretty RARE when they are managed by Knowledgable and Experienced anticoagulation managers. Did anyone ever come up with an explanation for your Very Unusual experience with Coumadin ?
The Most Common Reason for Unstable INR with patients in this country
is Poor Management by a Poorly Trained or Out of Date Manager.
The Certified Registered Nurse Practicioneers (CRNP) at my Coumadin Clinic are EXCELLENT.
Getting back to the original poster's question, I test once a week normally, with an extra check 4 days after a corrective change in dose. I'm sure I could get away with fewer tests but the strips cost me only about 4.65 ea, or the price of a chocomoccalattecino, and I like knowing. Recently I found that I was creeping lower, all the way to 1.8 (I think perhaps due to a workout intensity and duration that was creeping higher) and found that I needed to increase my dose by 10.5mg/week! (I now take 11mg/day, up from 9.5). I made the change quite slowly and monitored it's effect over 3 weeks, testing every 4 days. I seem to be stable in range now, as I was for over a year at 9.5mg/ day.
I also eat greens daily and credit in part for my stability.
I have no experience with health insurance paying for medications or test equipment so I can't help there.
I also eat greens daily and credit in part for my stability.
I have no experience with health insurance paying for medications or test equipment so I can't help there.
Sarah_Louise
Well-known member
Im on "innohep tinzaparin heprin sodium" to give it it's full tittle
When i've asked in the past, i've been told it different to enoxaparin/Lovenox injections so not sure :/
They said my body was absorbing the warfarin too quickly and basically i was a medical mystery.....
Well like i've said my heamatologists and cardilogists are one of the top in the county, they look after many people so to be honest with in my eye's they are EXCELLENT and are keeping my best intrests at heart when they are looking after me.......
(Sorry dmeehan for takin ova yor thread) xx
ALCapshaw2
Well-known member
Sarah Louise -
Your case is indeed unique (and extremely Rare).
Everyone that I recall who has held the Coumadin / Warfarin for 2 Days has reported that their INR "Dropped like a Rock". You are the ONLY person I've encountered who reported that it continued to rise. It makes me wonder about the Quality / Consistency of your Lab Testing. This was a fairly common problem before development of the INR Testing Protocol but should be a thing of the past now.
I find it strange that your Doctor's aren't trying to understand the Cause of your very unusual reaction to Coumadin and /or unusual Lab Test results. To my mind, there remain a Lot of Unanswered Questions about your very unique case that would be in great interest to the Medical Community in general and especially to the Anti-Coagulation Specialists around the world.
Your case is indeed unique (and extremely Rare).
Everyone that I recall who has held the Coumadin / Warfarin for 2 Days has reported that their INR "Dropped like a Rock". You are the ONLY person I've encountered who reported that it continued to rise. It makes me wonder about the Quality / Consistency of your Lab Testing. This was a fairly common problem before development of the INR Testing Protocol but should be a thing of the past now.
I find it strange that your Doctor's aren't trying to understand the Cause of your very unusual reaction to Coumadin and /or unusual Lab Test results. To my mind, there remain a Lot of Unanswered Questions about your very unique case that would be in great interest to the Medical Community in general and especially to the Anti-Coagulation Specialists around the world.
Because you asked - the word is spelled Fluctuate. (Once you say it a few times, you won't misspell it again -- the UCTU sound is much different from UXU) It sounds like your INR was on a rollercoaster because of poor management. Testing every day or two doesn't really give the whole picture about your dosages or your system's response to the dosing. Taking you off warfarin completely, then testing the next day and finding your INR increased has little or nothing to do with your missed dose.
It doesn't sound like your doctors -- they can be the best in the world but they may not be up to date on anticoagulation management -- really took into account the latency of warfarin. Sure - your INR may have gone up the day after you skipped a dose - but the rise was because of doses you took DAYS before - not because you missed a dose. Testing a few days LATER would probably have shown the decreased dosage.
Heparin injections work on a different clotting mechanism. I don't use heparin injections, but aren't they expensive? And aren't they kind of painful? Compared to a dime a day for warfarin, a daily injection doesn't sound so great.
I wouldn't conclude that warfarin and you don't get along (although this does, rarely, happen to some people). I think that warfarin and poor management and you don't get along. I suggest that you try again - perhaps with an anticoagulation clinic - and realize that the effect of your dosage today won't be seen for a few days. Realize, too, that some people may take longer (and some may take less time) to show the effects of dosage changes. Making multiple modifications - and expecting the results right away - are providing bad data that knee jerk reactions (frequent changes in dosing) will only cause to create a roller coaster effect in your INRs.
FWIW - my cardiologist didn't want to be bothered with such things as INR management - he preferred to let a GP spend his or her time on anticoagulation so that he (the cardiologist) can spend more time seeing heart patients. Your Hematologist may be of a similar opinion. (Is it possible that a hematological problem makes warfarin less than ideal?)
It doesn't sound like your doctors -- they can be the best in the world but they may not be up to date on anticoagulation management -- really took into account the latency of warfarin. Sure - your INR may have gone up the day after you skipped a dose - but the rise was because of doses you took DAYS before - not because you missed a dose. Testing a few days LATER would probably have shown the decreased dosage.
Heparin injections work on a different clotting mechanism. I don't use heparin injections, but aren't they expensive? And aren't they kind of painful? Compared to a dime a day for warfarin, a daily injection doesn't sound so great.
I wouldn't conclude that warfarin and you don't get along (although this does, rarely, happen to some people). I think that warfarin and poor management and you don't get along. I suggest that you try again - perhaps with an anticoagulation clinic - and realize that the effect of your dosage today won't be seen for a few days. Realize, too, that some people may take longer (and some may take less time) to show the effects of dosage changes. Making multiple modifications - and expecting the results right away - are providing bad data that knee jerk reactions (frequent changes in dosing) will only cause to create a roller coaster effect in your INRs.
FWIW - my cardiologist didn't want to be bothered with such things as INR management - he preferred to let a GP spend his or her time on anticoagulation so that he (the cardiologist) can spend more time seeing heart patients. Your Hematologist may be of a similar opinion. (Is it possible that a hematological problem makes warfarin less than ideal?)
My first year was testing monthly at a lab with a vein draw. YUK.
Then in 2007, I bought a home monitor and began testing every second week. It is amazingly simple.
Then in 2007, I bought a home monitor and began testing every second week. It is amazingly simple.
