How often do you test INR?

[lance]

Hi Norm
Last Friday I e-mailed, at least I think I did) the Ontario Ministry of Health asking which pharmacies/pharmacists are qualified. If memory serves pharmacists willing to learn are authorized to test. The problem as I see it is not enough professionals (MD's) either haven't heard of POC testing or don't feel they need to know. My spouse and myself are the only two patients buying strips at the local pharmacy so there's no need for him to learn. Spouse takes warfarin for A-fib. Should this happen to you get your own meter.

 

[catwoman]

My test frequency fluctuates <vbg>, but I try to do it every week-2 weeks.
My INR on about 1/13 was 2.7; on 1/20, it was 3.8. Same dosage/week. GO FIGURE.........
In retrospect, I was able to determine that my INR had increased because (1) I wasn't drinking enough water and (2) I was stressed due to health issues of my elderly parents, wreaking havoc with my normal eating patterns. No change in meds or exercise. So, I attributed it to slight dehydration and a decrease in food intake.
Dehydration will bump up your INR, because the concentration of warfarin in your blood will increase.

 

[ALCapshaw2]

Sarah-Louise

I concur with 'Protimenow's' assessment of your Improper Testing and Dosing Schedule.

As I've said before, it takes 4 days for Coumadin to become fully metabolized and effective SO,
if you test only 2 days after your stopped taking Coumadin, the Coumadin you took 2,3,and 4 days ago is still being metabolized. The DROP would most likely NOT Register until 4 to 6 days after you stopped taking the medication. Your hemotoligist may know a lot about Blood, but it would seem that he does NOT understand how long it takes for Coumadin to become fully effective and is changing your dosage based on an inaccurate understanding of this protracted process.

Even though you are taking Heparin shots now, it would be wise for you to make a chronological listing of your Coumadin Dose, INR Test Result, and Dosing Change. Then show this schedule to your Cardiologist and Primary Care Physician (or even a Dedicated Coumadin Clinic where there managers are Up to Date on the latest recommended procedures for Coumadin Management). It is clear that the manager you were using does NOT understand how long it takes for changes to be become fully effective and stabilize.

You may also want to ask your pharmacist about the Half-Life of the Heparin Shots you are taking and the usual recommended interval between injections, just to be sure that only one shot per day is safe. Again, as I mentioned previously, in the USA, LMWH is given Twice per Day, every 12 hours.

 

[Protimenow]

Al -- thanks for agreeing with my assessment.

Doctors prescribe dozens (if not many) more medications from a list of many thousands. Many of these have fairly rapid effects - take it now, and within a few minutes you're already getting benefits. They also have relatively short half-lives -- the pill you take today will probably be completely gone from your system in a day or less. Given these properties of MOST medications, it may not be surprising to think that a physician would expect something similar to happen with warfarin. Some doctors would have to be reminded (although some doctors really DON'T want to educated by their patients) about warfarin's latency, if not its method of operation. (I'm not sure many patients are familiar with how it works - nor should they be - but having some idea of how it works may be enough to get the doctor to crack open his or her PDR (Physician's Desk Reference) and REALLY learn about the medication).

Unless there's a hematologic reason why warfarin isn't working right, if I were you, I'd retry warfarin but be careful to do it slowly, acknowledging the length of time before the effects of a current dose are manifested, and gradually adjusting your dosage until it puts you in range - and, probably - keeps you in range.

 

[Protimenow]

My test frequency fluctuates <vbg>, but I try to do it every week-2 weeks.
My INR on about 1/13 was 2.7; on 1/20, it was 3.8. Same dosage/week. GO FIGURE.........
In retrospect, I was able to determine that my INR had increased because (1) I wasn't drinking enough water and (2) I was stressed due to health issues of my elderly parents, wreaking havoc with my normal eating patterns. No change in meds or exercise. So, I attributed it to slight dehydration and a decrease in food intake.
Dehydration will bump up your INR, because the concentration of warfarin in your blood will increase.

Even at 3.8, I'll bet you didn't adjust your dosage. On 11/12, I was at 4.1, and on 11/22 I was at 1.8 - no change in dosage. With the 1.8, I didn' t go running for Lovenox - these are just fairly normal fluctuations that can happen with imperceptible changes in hydration, diet, exercise, phases of the moon, or who knows what? I suspect that if I had a doctor who wasn't really familiar with anticoagulation management, she would have cut my dose when I had a 4.1, and pumped it up when I had a 1.8, and started me on a long, unmanageable roller coaster.

In most cases, once you're fairly stable, slight deviations out of desired range are just that -- and minor changes in dosage are probably all that's needed to stay in range. And, as Al and others have noted, giving your warfarin dosage changes 4 or 5 days to actually show effects is the correct way to monitor INR.

 

[Lynlw]

Sarah-Louise

I concur with 'Protimenow's' assessment of your Improper Testing and Dosing Schedule.

As I've said before, it takes 4 days for Coumadin to become fully metabolized and effective SO,
if you test only 2 days after your stopped taking Coumadin, the Coumadin you took 2,3,and 4 days ago is still being metabolized. The DROP would most likely NOT Register until 4 to 6 days after you stopped taking the medication. Your hemotoligist may know a lot about Blood, but it would seem that he does NOT understand how long it takes for Coumadin to become fully effective and is changing your dosage based on an inaccurate understanding of this protracted process.

Even though you are taking Heparin shots now, it would be wise for you to make a chronological listing of your Coumadin Dose, INR Test Result, and Dosing Change. Then show this schedule to your Cardiologist and Primary Care Physician (or even a Dedicated Coumadin Clinic where there managers are Up to Date on the latest recommended procedures for Coumadin Management). It is clear that the manager you were using does NOT understand how long it takes for changes to be become fully effective and stabilize.

You may also want to ask your pharmacist about the Half-Life of the Heparin Shots you are taking and the usual recommended interval between injections, just to be sure that only one shot per day is safe. Again, as I mentioned previously, in the USA, LMWH is given Twice per Day, every 12 hours.

Anything I read on INNOHEP says it is given once a day, like Sarah is doing.

I know in her previous post, she mentioned she home tested and has all her results from the 3 years since her 3rd heart surgery, when she was 13 (when she got her mech valve) in 1 notebook.
http://www.valvereplacement.org/forums/showthread.php?36397-Helloo-)

Sarah Louise, Again I want to say I think it is great how involved you are and how much you have learned about your heart and different surgeries and meds at your age. Your parents and doctors must be very proud of you. It will really help when you are a little older and have to make all of your medical decisions yourself that you understand so much now.
BTW Happy Belated 17th Birthday, I hope you had a good day.

 

[Sarah_Louise]

Right, How dare either of you! :mad2:
Your having a go at me and critising MY doctors, Yet you AREN'T doctors, you don't know my doctors, who im sure HAVE had all the training and ARE up to date! and i probably have more medical knowledge than you, after all i've grown up my WHOLE life with it,
They done there best for me!!!!!!! Sorry im not "normal" and follow the "normal trend" every single person is DIFFERENT, not two people on this forum you will find are the same!
SO before you critisize any more, think!!!!

Thank you Lyn i had a good day xxx

 

[Bina]

Sarah, I feel very badly for you if Al and ProtimeNow have hurt your feelings.
Some on here have very strong opinions and judgements where it's not necessarily needed.
((hugs)) to you

 

[Cooker]

Right, How dare either of you! :mad2:
Your having a go at me and critising MY doctors, Yet you AREN'T doctors, you don't know my doctors, who im sure HAVE had all the training and ARE up to date! and i probably have more medical knowledge than you, after all i've grown up my WHOLE life with it,
They done there best for me!!!!!!! Sorry im not "normal" and follow the "normal trend" every single person is DIFFERENT, not two people on this forum you will find are the same!
SO before you critisize any more, think!!!!

Thank you Lyn i had a good day xxx

Bravo Sarah Louise!!! ... about time the self proclaimed experts got put in their place ... many feel the same way as you and don't have the nerve to express it:thumbup:

 

[kfay]

Sarah Louise, you go girl! Don't listen to Al and Protime. Obviously, your parents and Dr's have done a decent job getting you where you are so far in life. None of us have any business trying to override their opinions about your health and care.

 

[Protimenow]

Sarah_Louise: One part of me says to ignore your rants and those of others who backed you up, apparently without reading the posts you complained about. I can't speak for Al, but for myself, my only goal was to assure your well being. I even asked you a few times if there may have been a hematological reason why warfarin didn't work the same way in you as it does in most others. (After all, you said you were seeing a hematologist who was one of the best in the world - didn't he or she have any idea what was going on?).

My valve replacement was done years ago by a surgeon who actually WAS one of the pioneers in the procedure, and who WAS one of the best in the country - he barely even mentioned anticoagulation management - except to tell me that after my surgery, I would have to take coumadin, and would have to have it managed by my GP. I suspect that most cardiac surgeons would rather spend their times practicing their specialty than 'wasting' it on anticoagulation management. I suspect that your doctors have a support team that may actually get involved in the non-surgical aspects of patient care, if a GP, anticoagulation clinic, or family practitioner doesn't assume the responsibility.

I don't think Al or I were TELLING you what to do. However, your report that you would get a dose on one day, and tested for results the next day led to an obvious conclusion that the people ordering these dosage changes and tests didn't know how warfarin worked. There's no refuting this. It's not an indictment of your world class doctors -- they shouldn't have to be concerned with INR management -- but the support system seemed to have failed you.

And Cooker -- I don't think that either Al or I EVER proclaimed ourselves to be experts. But -- you don't have to be an expert to know that it takes a few days for the effects of a dose of warfarin to be reflected in an INR, or to conclude that the real 'experts' testing a day after dosing are doing something wrong. And, Cooker, I don't think we were trying to override the doctor or parent opinions about care -- just to point out that with what appeared to be inadequate management it may have been somewhat premature to conclude that Sarah_Louise was not a candidate for warfarin if it was properly managed.

 

[Sarah_Louise]

Protimenow........
"My only goal was to assure your well being" my cardiologist, heamatologists, doctors and nurses, and family are all there for that, so to be honest, i don't need it, and if thats you "re-assuring my well being" i'd hate to see what you where like if you where my enemy!!

Several doctors, and heamotologists came up with an idea that my body was producing anti-bodies and fighting the warfarin, but you CAN NOT blame my doctors ect for "poor management" or whatever, becuase i've had 3 different heamotologists look at my case!!

Thats the difference then between your cardiologists and mine, mine takes care in other aspects of my health, rather than just my heart, so sorry if mine is more caring than yours! If i wanted i could have my GP take over my care, but a decicion was again made that MY doctors and nurses would control my anti-coagulation!!

Right so say if your INR was i don't know 6.7 one day, (taking into concideration at the time i was in a mainstream school with 1700 other children, moving around a school every hour from one lesson to another) and you didn't know your INR was that high, and you got pushed (as everyone does getting in and out of buildings) my heamotologist wouldn't ALLOW me to attend school because as you seem to know everything can be dangerous, so how would i know???? without testing it!!!!!! So i am sorry if my anti-coagulation managers wanted to keep an eye on me, but one thing you can't say is that my "support system seemed to have failed you" because that's one thing they HAVEN'T done, they have been and are amazing, 3 heamotologists, 2 cardiac liason nurses, 3 community nurses, cardiologists the list goes on, and each and everyone of them have been AMAZING!!!!!

Oh and you and Al aren't proclaimed experts, what this about then

Al -- thanks for agreeing with my assessment..

You a doctor now?!?

 

[Protimenow]

Why can't Al and I agree on something? Does this make either one of us an expert? It could make us equally wrong about something - just because we both agree on something doesn't necessarily make either of us an expert.

I don't think you should have to check your INR every day -- unless you've done something really strange with dosing a few days ago. Yes, I know what dangers you're facing with a high school full of kids who don't know the difference between etc. and ect., and who think it's fun to knock people into lockers.

From this point forward, I'll back off of any replies to you -- you're in the hands of your crack, world class, medical team.

(I'm still wondering if your hematologists (in the U.K. they're haematologists - in the U.S. they're hematologists) could determine why your response to warfarin was so atypical. It would be interesting to see what they conclude.)

 

[gjgaudia]

I must take issue with all the experts here (real or imagined) and argue that while frequent dose changes are undesireable, frequent testing, in and of itself, is most desireable. If one were to test daily, for example (I am not recommending that they do, but I see no harm in it), and keep a record of the results, then a trend line could be established so that if a low (or high) out-of-range reading were obtained then the person would be able to see which direction they had been trending, and change (or not change) the doseage accordingly. Suppose the last five daily readings were (assuming a therapeutic range of 2.5-3.5) 2.8; 2.7; 2.6; 2.5 and 2.4. There would be every reason to believe that the trend would continue downward and thus be out of the range in the next day or so. It would be helpful to increase the doseage in this example. On the other hand, if the last five daily readings were 2.8; 2.6; 2.7; 2.6 and 2.4 there would be no clear trend and the last reading could be an anomalie due to some dietary factor, other medications, other metabolic changes, etc., and no change in doseage would be warranted. At the very least, some of the guesswork is eliminated by frequent monitoring. Monthly monitoring, except in the most extremely stable individuals, in my opinion is suicidal. All you would know for sure is whether you were in the range on day one or day thirty, with 28 days where you could be anywhere, including in the emergency room.