INR has been 1.77 for two weeks...

[cuoricino]

Please help me! I'm really struggling.

I'm 3 and a half months post op and I just cannot get my INR under control. Everything was going really well until my doctor took me off amiodarone and I can't seem to get in range anymore. I have St. Jude valve in aortic position and my ideal range according to my surgeon is 2.5-3.5.

I started getting below range 6 weeks ago. I've listed the weekly number of mg I've been taking, evenly distributed throughout the week, and my INR reading for that week. The big jump in dose during the week of April 29 was just me getting impatient and frustrated and I took matters into my own hands with a higher dose (I didn't consult doc on that increase.... I know, I'm very stupid). The doctors don't seem overly concerned. They told me to skip a dose after that spike, and reccommended I start at a lower dose and keep increasing slowly. They honestly weren't so concerned as long as it was over 2 -- but now I've been at 1.77/1.76 for 2 weeks!

Unfortunately, because of the COVID mayhem, I don't have a regular cardiologist who has been following me, and getting proper consultation has been a bit of a challenge. Whoever I speak to keeps telling me to increase just a little bit each week. How nervous would you be with these numbers?

Week starting April 8
mg: 17.5
INR: 2.31 (tested April 15)

Week starting April 15
mg: 18.75
INR: 2.15 (tested April 22)

Week starting April 22
mg: 22.5
INR: 2.18 (tested April 29)

Week starting April 29
mg: 31.25
INR: 6.24 (tested May 6)

Week starting May 6
mg: 15
INR: 1.77 (tested May 13)

Week: May 13
mg: 20
INR: 1.76 (tested May 20)

 

[dick0236]

At 3-l/2 months your body is returning to normal and that will have an effect on your INR dosing. The adjustment from 22.5 to 31.25 mg per week was a big adjustment (40%) and the drop in INR should be expected. Try adding 15-20%/wk and bring it up more slowly. The 1.8s your getting are ok so long as they don't stay at that level long term. We all react differently to warfarin but I believe that "baby steps" are best when adjusting INR........unless there is some other problem going on.

 

[Warrick]

To keep a record and as a daily reminder I use an app called INRlog ,INR log app review | Health Navigator NZ
When you put in your dosing it tells you what percentage you are increasing/decreasing your dose by, you might find an app similar which you may find helpful.

I take around 67mg a week or 9,5mg daily, I was started out on 5mg a day and slowly had to increase up to where I am now over a few months, so having to increase your dose over several months after OHS is normal.

 

[cuoricino]

The 1.8s your getting are ok so long as they don't stay at that level long term. We all react differently to warfarin but I believe that "baby steps" are best when adjusting INR........unless there is some other problem going on.

Thank you! I'm an impatient person by nature, so I guess I don't understand what "long term" means in this case. 2 weeks seems like a long time to me, but I'm very new to this. The baby steps are also driving me up the wall because it seems that when I've done the baby steps, my INR stays constant or actually dips even though my dose increases. Thank you for your insight. I just don't know enough about all of this and the increased risk of stroke is really making me anxious. When I talk to a doctor they don't seem overly concerned and continue to suggest baby steps as you have. So I think I'm just trying to get double confirmation that it will all work out in the end.

To keep a record and as a daily reminder I use an app called INRlog ,INR log app review | Health Navigator NZ
When you put in your dosing it tells you what percentage you are increasing/decreasing your dose by, you might find an app similar which you may find helpful.

Awesome - will definitely check this out. Thank you!

 

[Dodgy Ticker]

Hi Cuoricino

I sympathise enormously with you,, but in truth you have no choice than to REALLY make an effort to be patient and calm about these things. INR can fluctuate wildly from time to time - often without any obvious reason. And because your body will take 3-5 days to readjust to a change in dosage of Warfarin, there is little else you can do than being patient.

Having been on this for 18 months now, I am also relatively new to the whole business, but patience is starting to work, and the results are a reduction in stress.

This will be with you for the long term, so you HAVE to get into the swing of it - however frustrating!!

Good luck.

 

[LondonAndy]

The baby steps are also driving me up the wall because it seems that when I've done the baby steps, my INR stays constant or actually dips even though my dose increases. Thank you for your insight. I just don't know enough about all of this and the increased risk of stroke is really making me anxious. When I talk to a doctor they don't seem overly concerned and continue to suggest baby steps as you have. So I think I'm just trying to get double confirmation that it will all work out in the end.

I agree with what others have said, and it sounds as if you already know that Warfarin takes about 3 days to reach full effect. But sometimes if I have had a surprise drop in INR, I take what I think is called a "loading dose" - ie a one-off increase in my Warfarin, then back down to regular dose for the next 2 days before testing again on the third day after. I have the same range of 2.5 to 3.5, and take 7mg per day usually. So if I dropped below 2 I might take 10mg the next time I was due to take it, then back to normal. If the test on day 3 was up a bit but not enough, I would up my daily dose to 8mg and test again in 3 days to see if that is my "new normal". Usual caveat that I am not a doctor, just a fellow AVR recipient.

 

[pellicle]

Please help me! I'm really struggling.

I'm 3 and a half months post op and I just cannot get my INR under control. Everything was going really well until my doctor took me off amiodarone and I can't seem to get in range anymore. I have St. Jude valve in aortic position and my ideal range according to my surgeon is 2.5-3.5.

I started getting below range 6 weeks ago. I've listed the weekly number of mg I've been taking, evenly distributed throughout the week, and my INR reading for that week. The big jump in dose during the week of April 29 was just me getting impatient and frustrated and I took matters into my own hands with a higher dose (I didn't consult doc on that increase.... I know, I'm very stupid). The doctors don't seem overly concerned. They told me to skip a dose after that spike, and reccommended I start at a lower dose and keep increasing slowly. They honestly weren't so concerned as long as it was over 2 -- but now I've been at 1.77/1.76 for 2 weeks!

Unfortunately, because of the COVID mayhem, I don't have a regular cardiologist who has been following me, and getting proper consultation has been a bit of a challenge. Whoever I speak to keeps telling me to increase just a little bit each week. How nervous would you be with these numbers?

Week starting April 8
mg: 17.5
INR: 2.31 (tested April 15)

Week starting April 15
mg: 18.75
INR: 2.15 (tested April 22)

Increase your dose to get the desired INR, nothing more, nothing less.

INR is the goal, eat what it takes.

Also, toss the weekly dose thinking in the trash, it was passed it's use by date when we stopped thinking of "blood in your urine is a sign" or prothrombin time. (So, like the 1970's)

As is already mentioned, as you recover your dose goes up.

INR is the only measurement.

 

[pellicle]

Having been on this for 18 months now, I am also relatively new to the whole business, but patience is starting to work, and the results are a reduction in stress.

Hey dodgy

I hope this helps
https://cjeastwd.blogspot.com/2014/09/managing-my-inr.html
https://cjeastwd.blogspot.com/2014/05/inr-management-goldilocks-dose.html

 

[user 15848]

Just a thought, from hospital to home what we eat starts changing, and we all eat different combinations of things and those choices may require a higher dose of the pill

Nothing to worry about; lets say you eat lots of Broccoli, good for you, but since has lots of Vit-K then you may need a little more of Warfarin, not a problem, what is important is to be consistent in what kind of food you eat or drink;

Because of my food choices INR tends to go above my desired high level; and then i just take 0.5 mg less per day for 1 week and test;

Like many people say here " test weekly" and probably best do self testing at home and keep consistent; many people like myself use a Coagucheck machine, others use other machines, you can research that and consider getting one

 

[LondonAndy]

Like many people say here " test weekly" and probably best do self testing at home and keep consistent; many people like myself use a Coagucheck machine, others use other machines, you can research that and consider getting one

In case you haven't come across this before in your readings on this site @cuoricino here is my amateur summary of a report by the UK's National Institute of Clinical Excellence from September 2014, setting out the benefits of people on Warfarin home testing, which includes a link to their full report and which they have updated slightly since 2014.

 

[Protimenow]

You didn't say which valve you have - but even if it was an On-X, I would be more comfortable with an INR above 2.0, and ideally around 2.5 or so.

I would worry about an INR below 2 - the risk of stroke goes up quite a bit. I've seen a reporte by Duke University Clinic that said that even 10 days below 2.0 a clot can develop, and this can cause a stroke. Personally, I had my INR reduced a few weeks ago so I can have an ablation - it took me a while to get the level back up - but with my regular dosage, it took almost a week.

I agree with Pellicle - don't go by weekly totals. As others have said, today's dosage won't show up in your INR testing for about 3 days.

And, as others have mentioned, adjustments of about .5 mg a day should be the first steps to take if your INR is out of range, or you need to slightly raise or lower the INR.

And, as noted in other posts, if you binge on greens, you probably shouldn't change your dosage - in a few days, the INR should return to normal. And, as others have suggested, try to keep your diet consistent - once you determine the correct dosage for your consistent diet, your INR should stay in range.

Right now, I'm dealing with a slightly different issue - absolutely related to INR. I now have to go to an anticoagulation clinic, and I go on Wednesday. When I go, I want to show up with an INR that's in range.

I have two meters - and they now seem to be varying by a whole point - a 2.5 on one meter is a 3.5 on the other (this is the meter that the clinic uses). Yesterday, the readings were 2.8 and 3.8 -- neither result was problematic. I just reduced my dosage by one full mg (from 7.0 to 6.0), expecting the meters to read 2.0 and 3.0, and satisfying the clinic.

Both manufacturers still stand by the accuracy of their meters. Others on this site report strong correspondence of the 'low' meter with labs. I'm baffled by the difference in results - perhaps it's something I said? Clotting time is clotting time - I'm at a loss to explain sucn a large difference between meter and meter and, probably, between meter and lab.

I may report on what the clinic's CoaguChek XS reports.

 

[drivetopless]

Yes- wondering what kind of valve you have?
I remember that my INR did not settle down for a good year after surgery. It helped when I strated taking a multivitamin with vita K every day and when I started eating a salad/greens EVERY day. The greens part is about being consistent. When my INR gets out of whack its because my diet has become inconsistent.

I would not panic. It will level out as long as your diet and lifestyle is consistent. Take your coumadin at the same time every day. I take mine at bedtime.

Also over time you will learn how your body responds to Coumadin and will be more comfortable with dosage adjustments. I do seem to need to adjust mine seasonally +/- 5-10 mg per week.

 

[Protimenow]

I'm not sure if 'same time every day' has a lot of effect on warfarin, because it takes so long to see the effect on INR.


L:ike drivetopless, I also take mine at bedtime -- it's easier to remember if you take it at the same time each day.

As far as Vitamin K is concerned - it's K1 that affects the INR. Recent research suggests that taking a consistent amount of K1 daily, and adjusting your dose to adjust to the effects of K1, can make it easier to get in range and stay in range. (Plus, K1 has health benefits that most of us can't receive because we aren't taking it).

 

[pellicle]

Just a thought, from hospital to home what we eat starts changing, and we all eat different combinations of things and those choices may require a higher dose of the pill

essentially you'll be much better off if you simply ignore diet and just focus on living life and once a week for 10 minutes take your INR and make a judgement based on the history (you're recording it all of couse) of your situation to see if you need to alter hold a teeny bit, or increase a teeny bit.

Work ONLY in mg per day and keep every dose as close as possible (ideally identical but 0.5mg alternations are of little consequence.

The actual well documented reason for the raise in dose requirement in post hospital recovery is blood serum albumin changes in recovery.

http://dx.doi.org/10.1016/S0002-9149(99)00463-4

The response to initiation of oral anticoagulants at a usual dose of 5 mg of warfarin has been retrospectively evaluated in patients following heart valve replacement (HVR). Patients starting oral anticoagulants after HVR have a lower target International Normalized Ratio (INR) (1.5 to 2.6) until the pacing wires are removed after operation. The mean daily doses and INR responses after HVR and nonsurgical patients were retrospectively compared during the first 5 days of warfarin treatment. In a subset from both groups, the mean dose of warfarin was correlated with age, body weight, and albumin levels. Eighty-four HVR and 32 nonsurgical patients were studied. The mean daily warfarin dosage was 3.29 ± 1.29 mg after HVR and 4.96 ±1.76 mg in controls (p <0.001), and the mean INRs 2.08 ± 0.60 and 1.60 ± 0.54, respectively (p <0.001). Of the HVR patients and controls, 48.8% and 21.8%, respectively, exceeded the upper level of the targeted range (p = 0.014), 86.9% and 40.6% had the dose reduced after the first 5 mg (p <0.001), and 54.7% and 28.1%, respectively, had warfarin withheld for at least 1 day (p = 0.015). Thirty-nine patients were included in the subset analysis. Patients with serum albumin levels <35 g/L required significantly less warfarin (3.84 mg/day) than patients with levels ≥35 g/L (5.37 mg/day; p <0.05). Thus, patients starting oral anticoagulation after HVR are significantly more sensitive to warfarin than nonsurgical patients. Patients with serum albumin levels below the normal values require less warfarin than patients with normal values during the initial phase of treatment.​

known to science for over 20 years now, but somehow missing from the knowledge base of (supposedly) professional INR clinics ... who'll still spout ancient medical history as best practice.

But hey, INR management is always a sideline circus for labs whos' actual business is in other pathology, and anyway, why get involved with selling you on their services by offering modern best practice when the rest of the medical industry works hand in glove to make sure you feel more like a prisoner than a client (with choice to vote with your feet) ... (*well in the USA anyway)

 

[cuoricino]

Thanks for the insight all! Valve is St. Jude in aortic position. Dose is always prescribed daily... I just listed in weekly amounts for clarity and brevity.

I'm most concerned about the comment of clots forming in just 10 days leading to stroke. I guess I'm past 10 days at this point, but each day that passes would seem to increase risk and the weekly tests don't seem frequent enough, so I may up to 2 times/week after Wednesday's check...

I will look into home testing eventually, but for now I go to a clinic every week which I prefer until I can get my levels under control.

 

[Protimenow]

The thing about stroke occurence after as few as ten days was not an absolute. I'm sure that many people can go much longer without any adverse events. That said, it's a good idea to get control of your INR and try not to go for long with an INR below 2 (and probably closer to 2.5).

If using a clinic works for you, and lets you test weekly -- and you don't mind going to and from the clinic, waiting your turn, and putting up with the other inconveniences, the clinic may be a good choice for you. However, if you can, try to manage your dosing if the clinic isn't keeping your INR in range. I did this years ago when I had to go to a clinic - I used my own meter, compared results to the clinic's machines, and managed my own dosing. At the clinic, I was 'Mr. Consistent.' Of course I was - using my meter and self-management I was always in range.

 

[pellicle]

I'm most concerned about the comment of clots forming in just 10 days leading to stroke.

the St Judes is a solid valve with a great track record. I wouldn't be worried ...
keep abreast of your medications, impliment a pill box, do so in a way that gives you a triple check:

1. an alarm that reminds you to take it (and take it)
2. a pill box that's dated so that you can check at taking that you took yesterdays while taking todays (confirm the actual day)
3. a position for the box that enables you 12 hours later (like your next major meal) to check "did I take it"

I've found you need all three

 

[cuoricino]

Again- thank you all!

Today, I was finally able to get set up with a cardiologist who will "accompany" me on this journey

He reviewed my log, said it looked good. Will bump me to twice weekly blood draws until I'm solidly in range. Gave me his cell number to send him my results each time so we can adjust as needed. Hooray!! The cloud of COVID has lifted for now in Italy and we can finally get access again to non-COVID services. Feeling so grateful and more supported as I practice patience while wading through this new (for me) world of INR.

 

[Protimenow]

Pellicle's advice, as always, is absolutely correct.

It's what I do:

I take my warfarin the same time each night (my wife takes her medications at that time, and I have an alarm on my phone to remind us).

I use a daily pill case. I make up a week's worth of medications on Sunday. It may be best to put your daily dose of warfarin in first, to make sure you don't somehow forget it. (I forgot once - but I have no plans to repeat this. I tested on a Wednesday that week, saw that it dropped, checked the pill box and immediately noticed that I left the warfarin out - this WON'T happen again).

I have the box in a location where it's always staring at me. I usually don't check the box in the morning, unless something tells me that I missed my dose from the night before.

Once you develop a routine for taking warfarin (and anything else that you take at a certain time), you should be ableto get your daily dose consistently -- without worrying about having missed a dose or taking double dose because you weren't sure if you missed a dose.

 

[pellicle]

as I practice patience while wading through this new (for me) world of INR

well feel free to ask questions here