INR of 1.0 with mechanical valve

[corabell]

Hello all, I've been reading your forum for months and learning so much from all of you, so first thank you for sharing your stories and information.
I joined here because my husband had a bicuspid valve with severe aortic stenosis replaced the last week of February with an On-X mechanical valve. He left the hospital after 5 days, they had to wait until his INR was in range and it was 2.4 the day he left. The Coumadin clinic immediately called him that night and told him to take 1/2 tablet (1.25 mg) of Warfarin and have his blood tested the next day. He did that at the lab and it was 1.8. They told him to retest in 2 days, he did and it was 1.3. That was over this past weekend so calls to them were not answered, he called his surgeon's after hours service and they said to start taking the full 2.5 mg tablets again and re-test on Monday, today. Today's results were 1.0.

He's never had to take meds before in his life, he's 50 years old, active, and in good health other than the valve he had. He was sent home from the hospital with Amiodarone 200mg for 30 days, Aspirin 81 mg, Colchicine for 10 days, Metoprolol 25mg twice a day, Pantoprazole 40mg for 30 days and Warfarin 2.5mg.
Needless to say I'm freaking out about this low INR that has only dropped since his release on 3/1, almost a week ago. It's like he's not taking a darn thing to thin his blood!?! He has calls in now to his surgeon's office, cardiologist and Coumadin Clinic and waiting on their instructions. He hasn't eaten any leafy greens or any Vitamin K foods or drinks that we know of that would affect it.

I guess I'm looking for possible reasons as to why his INR is just dropping. From what I researched, Amiodarone should be making the INR even higher, as well as the aspirin he's taking. Any guesses or things we may not be thinking about? Is there something he can do to up the INR on his own since the people on the phones don't seem too concerned, which is maddening. I know we are new to all this and maybe I'm over-reacting by freaking out, so any advice? Thanks for letting me rant, wish it didn't have to be in my first post here

 

[Superman]

Welcome to the forum and glad to read that your husband is home and recovering. I’m 49 myself and take warfarin, metoprolol, and a baby aspirin daily. I received my valve at 17 and had an aneurysm repaired when I was 36.

As far as INR. Initial dosing can always be a challenge because recovering from open heart is very taxing on the body with your metabolism trying to sort itself out.

He did go back to his regular 2.5 mg dose, correct? Usually a half dose is a one day thing. The easiest thing to do in this case (especially at a 1.0 INR is to simply take another (extra) dose and let the clinic know what you chose to do. But I also have more experience dosing warfarin for myself than anyone at my Coumadin clinic does (close to 32 years now).

I’m sure you’re not to that comfort level yet, so don’t just do what I would do. I would recommend having that conversation with your providers as in, “How should we handle something like this in the future when we can’t reach anyone?” Just so you and your providers are on the same page.

Glancing at your initial post, there seem to me some misconceptions that are fairly common with warfarin. Avoiding greens, for example, is rather dated thinking. The reality is if your diet is consistent and includes greens, your dose will account for that. The only proper dose is the one that keeps you in range. I currently alternate 5 and 6 mg’s daily. Some here take over 10 mg’s daily. It’s not really age or weight or gender based either. It’s just how your body metabolizes the medication.

Some others will be along with a lot more thorough and detailed thoughts as well. Keep us posted, and welcome your husband to the zipper club for us.

 

[Chuck C]

Welcome to the forum Corabell.

Today's results were 1.0.

Is there something he can do to up the INR on his own since the people on the phones don't seem too concerned, which is maddening.

He has calls in now to his surgeon's office, cardiologist and Coumadin Clinic and waiting on their instructions.

Dropping to an INR of 1.0 is a big concern and requires immediate action. Hopefully his calls to the surgeon, cardiologist and Coumadin Clinic are returne very soon. I would think that they will probably want to put him on a bridge anti-coagulation until his INR gets back into range.

The fact that his INR is so low means that he needs a higher dose of warfarin to get him into range. Speculation as to what is causing it to be too low may not lead you to any conclusions.

You indicated that he was released on 200mg of amiodarone. You are correct in that this usually makes INR go high. I had the opposite issue upon release from hospital with an INR that shot high due to being on amiodarone. Amiodarone is usually prescribed to control afib, which is very common afte valve surgery. Did he have afib while in the hospital and was he put on amiodarone while in the hospital? 200mg is a low dose of amiodarone. As a frame of reference I was put on 800mg upon release to control my afib. What I am wondering is whether he was on a higher dose of amiodarone while in the hospital? If so, this could have caused him to be in range at a lower dose of warfarin while in hospital. Also, amiodarone in the hospital would usually be given via IV. For example, if he was on 800mg of amiodarone per day of amiodarone, by IV, it may have given some misleading data as to what dose of warfarin would be needed to keep him in range. If his amiodarone dose then was significantly dropped and moved from IV to oral, then perhaps the effect of amiodarone causing an elevation of INR would be much less in play and a higher dose of warfarin may be needed.

From my own experience, amiodarone can wreak havoc on INR. When amiodarone is added or the dosage alterened, either up or down, there should be frequent testing of INR to determine if it is having an effect- it likely is. As an example of how much amiodarone can affect INR- my INR went from 3.1 t0 9.7 in 3 or 4 days, once I was on amiodarone. The amount of warfarin I needed to stay in range was dropped to about 50%. As amiodarone was gradually reduced, I needed much more warfarin to stay in range. So, if his amiodarone dosage was dropped suddenly, more warfarin may be needed to compensate.

Get medical care and get it soon. If none of his calls to the medical professionals are returned, and their offices continue to not take it seriously, I would go to the ER.

 

[corabell]

Thank you for the replies and suggestions. I'll try and answer some of the questions. I don't think he had any afib in the hospital, if he did, it wasn't relayed to us. Yes he went back to 2.5 mg of Warfarin on Friday when the surgeon's office called him back after hours.
I appreciate your input Superman and Chuck C. I also suggested to my husband the ER may be where we need to go if they have something that can bring the INR up right away, but I felt maybe I was over-reacting since we are so new to this lol. Hoping to hear from a Dr. or clinic, anyone?! soon....and hoping they take it seriously, if not I guess we are headed there.

 

[Chuck C]

I appreciate your input Superman and Chuck C. I also suggested to my husband the ER may be where we need to go if they have something that can bring the INR up right away

The bridge will not be something which makes INR go up quickly. It would likely be heparin or Lovenox, which play a role in a different part of the anti-coagulation chain and their effect is not measured by using INR. He may be put on one of these anti-coagulation bridges, while his warfarin dose is increased. Once is INR is in range from the warfarin, he would then be taken off of the bridge.

 

[Superman]

Yeah. Lovenox isn’t super fun. Self administered syringes to abdomen twice a day until you’re in range. Had to use it twice for surgeries after my first AVR that required me to go off warfarin.

And when you’re made of steel, you waste a lot on broken needles.

 

[pellicle]

Hi and welcome

ok, I'll take this in the order which I believe is the most important

I know we are new to all this and maybe I'm over-reacting by freaking out, so any advice?

as a first priority get that INR back up; this is only done by taking how much warfarin you need. I strongly advise that you get into heparin in the mean time. Heparin is another anticoagulant and works differently. Its action is not measured by INR nor does it influence the INR you read.

I believe you should commence heparin immediately and continue it until your husbands INR is in range again. That means an INR of at least 2. Speak to your doctor as a matter of priority.

He left the hospital after 5 days, they had to wait until his INR was in range and it was 2.4 the day he left.

good ... now, and this is important: what was his daily dose in milligrams (mg) at that time. (I read later it was 2.5mg ...)

because what follows from the clinic seems like complete crap

The Coumadin clinic immediately called him that night and told him to take 1/2 tablet (1.25 mg) of Warfarin and have his blood tested the next day....

Needless to say I'm freaking out about this low INR that has only dropped since his release on 3/1, almost a week ago. It's like he's not taking a darn thing to thin his blood!?!

its because the clinic told you to reduce his dose ... which was completely unfounded with an INR of 2.4 >unless there is something you are not telling us, like an INR reading that is high<

as an aside I want to nip this in the bud right here:

He hasn't eaten any leafy greens or any Vitamin K foods or drinks that we know of that would affect it.

eat leafy greens, eat a good diet and don't listen to anyone who says you shouldn't.

I guess I'm looking for possible reasons as to why his INR is just dropping. From what I researched

,

well with very little information its because his does was reduced.

Resume the dose he was on in hospital. Then know that in the weeks after release from hospital as you heal its entirely normal that the dose you need to maintain a proper theraputic INR will increase. There is no real point in going into the why of it.

There is only one rule in INR management: dose according to the INR reading.

Amiodarone should be making the INR even higher,

agreed.

Is there something he can do to up the INR on his own since the people on the phones don't seem too concerned, which is maddening.

yes, and that is what I've said. To increase the dose. However it is important that you don't just go wild with it and it must be done in conjunction with measurement. Do you have an INR meter? If you don't and if you can afford to buy one just do it.

Reach out if you want some direct assistance from me (here in Australia) ... happy to call (direct message me with your details if you like).

Best Wishes

 

[pellicle]

. Yes he went back to 2.5 mg of Warfarin on Friday when the surgeon's office called him back after hours.

good to read that.

I've not fully caught up on what Chuck and Superman have said, but I know it will be "the right stuff"

C. I also suggested to my husband the ER may be where we need to go if they have something that can bring the INR up right away,

nothing will bring your INR up right away, it just doesn't work that way. However Heparin will restore a safe level of anticoagulation right away because it does not work the same as warfarin and (as I said above) does not reflect in INR (which is only useful as a measurement of anticoagulation caused by warfarin).

I would go to the ER as a matter of priority and:

1. get a heparin shot
2. get them to measure INR
3. see about a prescription of heparin

I would remind the clinic of their duty of care and their failure to properly manage the dose of your husband has been gross negligence. Contact your insurance company and explain this. Also please pass by us here any future dosing information they may give.

Lastly (since your husband has not been on medications before) I strongly recommend the following:

1. get a daily pill box (you know, with days)
2. administer the warfarin into those pill box slots and double check what you've put in
3. set an alarm on your phone for a specific time when you'd take warfarin (in my case its 7pm when I'm either making or taking dinner): take the warfarin at that time
4. leave the pill box in an obvious place where it will be seen during daily activity and allow you to check issues like "hey, its tuesday, why isn't mondays dose taken"

Best Wishes

 

[corabell]

Thank you for all your replies! I haven't read all the posts yet, just wanted to update and say he had to call them back, no one called him...he got the surgeon's office and they instructed him to take 5 mg warfarin tonight and 3.75 the next 2 days and retest on Thursday. He has a post-op appt on Wednesday so hopefully they'll test then, too. He doesn't want to go to the ER, but he mentioned it to them on the phone and they didn't seem concerned enough to tell him to go, I still think he should, but can't make him
Reading through some questions:
Sadly, I don't know what dose of Warfarin he was on in the hospital, I do know he was on a Heparin IV until the day he left. He was supposed to get out on Monday but his INR never went above 1.5 until Tuesday when it was 2.4, that's the day they let him out and the same day the clinic called and told him to reduce his dose.
I have been learning about the green stuff. I only mentioned it in my original post because one of the nurses he talked to last week asked him if he was eating spinach or leafy vegetables...that tells me something right there, I guess. He normally eats all kinds of stuff like that but I actually advised him against it when I saw his numbers plummeting, just because I didn't want the levels to go any further down.
He has pill containers for AM and PM and he takes the meds same time each day and night (he also takes the warfarin at 7pm). I bought the pill box because of tips on this board.
I also wanted to have a home tester before he got out of the hospital but haven't done it yet, I'm mad at myself that I didn't. I left off researching them and haven't had a chance to get back to it. I believe I saw the Coagucheck XS was the favorite? I really thought we researched enough to help make this easier and it's just been frustrating and nerve wracking since the tests went downhill.

 

[Superman]

Don’t beat yourself up too much. A lot of times it’s nobodies fault and there isn’t much more you can do. Remember that he’s just been hit by a proverbial truck and the all the bodies energy is focused on healing. It can be a while for things get normal and somewhat predictable.

After my last open heart I dealt with pancreatitis that took a few weeks to resolve. And my teeth hurt for weeks. I was told I bit down on tubes during surgery and the constant bite pressure for hours left me with some soreness. Couldn’t eat anything cold or hot or sweet for a long time. Temperatures hurt my teeth and sweet stuff tasted awful. I had already been on Warfarin for 19 years at that point, but my old usual dosing didn’t work anymore and it took a while to regulate that as well.

He’ll get there.

 

[pellicle]

@corabell

I think that this summarises things well

Don’t beat yourself up too much....

He’ll get there.

the thing is that these things aren't time critical to the second, and I am using strong terms because I see too many cases of people being lackadaisical (clinics too) in the management of INR.

So just re-read the posts here in this thread and move forward, no panic needed, but totally move forward.

You now know what you need to know and its hard to know what you need to know from just reading the plethora of information available.

To add to what I said about what's needed (the pill box) I recommend strongly you start to document dose and INR yourself. Again reach out for details but I I recommend you follow something like this:

https://docs.google.com/spreadsheets/d/1TTAPucsS2_z2uXZjUdZUONExonqLRQV6n2zn2cwOf8Y/edit?usp=sharing
copy that to your Google Drive (or download it) and go with that. Reach out if you have questions. Worth noting is that this sheet uses a date format common in most of the world but apparently not the USA, just be aware of that.

I recommend just sticking with weekly measurements and try to keep your daily warfarin dose as consistent as possible. It doesn't matter what that dose is, it just matters that the INR is in range (between 2 and 3). The Amiodarone is going to give you a rocky ride until he gets off that.

 

[pellicle]

Oh, and about the greens:

https://www.ncbi.nlm.nih.gov/labs/pmc/articles/PMC4998867/

...We found conflicting evidence on the effect of dietary intake of vitamin K on coagulation response...​

​

The available evidence does not support current advice to modify dietary habits when starting therapy with VKAs. Restriction of dietary vitamin K intake does not seem to be a valid strategy to improve anticoagulation quality with VKAs. ​

​

...While some studies found a negative correlation between vitamin K intake and coagulation stability, others suggested that a minimum amount of daily vitamin K is required to maintain an adequate anticoagulation.​

​

In conclusion, the available evidence does not support current advice to modify dietary habits when starting therapy with VKAs. Restriction of dietary vitamin K intake does not seem to be a valid strategy to improve anticoagulation quality with VKAs. It would be, perhaps, more relevant to maintain stable dietary habit, thus avoiding wide changes in the intake of vitamin K. Based on this, until controlled prospective studies provide firm evidence that dietary vitamin K intake interferes with anticoagulation by VKAs, the putative interaction between food and VKAs should be eliminated from international guidelines. ​

my take on the psychology of this is this: the further down the food chain you go in medicine the more likely you will find "black and white thinking" and "strong assertions of opinion", the worst being the reception desk or those who aren't even clinicians. The further up the chain you go you will find a reliance on good peer reviewed papers, quality journals and some hesitancy and doubt around the edges. Essentially a willingness to say "it depends" on many things.

Look for that in what you read and are told and always research on quality sites such as I've just cited. If any site is an ad fest, just close the window.

Best Wishes

 

[pellicle]

believe I saw the Coagucheck XS was the favorite?

well it depends, for me its the only one even worth thinking about, not least because its the only one I can even readily get strips for

I don't know your financial situation, but I would look at this one and get some strips from eBay too ... take careful note of the use by date and that the box is unopened and comes with the code strip.

https://www.ebay.com/itm/224662255925
also if you haven't read my post on the topic here it is (sorry, its detailed but you can start at the top and just go down as you need to

http://cjeastwd.blogspot.com/2014/09/managing-my-inr.html
Take your time.

 

[corabell]

I promise, I'm going back to read all these posts, we've just been back and forth on the phones with Dr.s and people since I told him to "mention" Lovenox shots like you guys suggested and he immediately got calls back with prescription to get pens. I feel better with this, now dealing with our regular pharmacy not having them in stock and having to call around to find them...wow.
Edited the name of the med, lol

 

[pellicle]

Lovenox

is a company name, like Ford "Explorer" ... the actual product is known as Heparin

as long as you understand that you won't be confused by things. I think that the product Lovenox is not sold under that name in (for instance) Australia. There is no magic in the name.

 

[Superman]

is a company name, like Ford "Explorer" ... the actual product is known as Heparin

as long as you understand that you won't be confused by things. I think that the product Lovenox is not sold under that name in (for instance) Australia. There is no magic in the name.

Lovenox (Enoxaparin) and Heparin are two different drugs. Lovenox has a longer half life allowing for once daily dosing vs Heparin twice a day.

https://www.singlecare.com/blog/lovenox-vs-heparin/#efficacy

 

[pellicle]

Lovenox (Enoxaparin) and Heparin are two different drugs. Lovenox has a longer half life allowing for once daily dosing vs Heparin twice a day....

ok, so I should have said "is a heparin" ... getting a wee bit pedantic here, but ...

https://www.drugs.com/mtm/enoxaparin.html

https://en.wikipedia.org/wiki/Enoxaparin_sodium

Enoxaparin is in the low molecular weight heparin family of medications ​

 

[Superman]

I don’t know. One shot a day vs a shot every 8 to 12 hours. I wouldn’t take heparin over Lovenox even if they are cousins. It’s more than just a brand name Heparin.

It’s a pedantic hair I don’t mind splitting.

To me, the same means interchangeable with no tangible benefit to one over the other. Coumadin vs generic Warfarin is the same.

 

[pellicle]

It’s a pedantic hair I don’t mind splitting.

I'm not debating the various half lifes, I'm debating your statement that its "not heparin" and furnished evidence it was.

There are other products (as I pointed out) that are the exact same type of heparin with the same half lives but are not called Lovenox. I raised the issue to diffuse any possible anxiety that the OP may have had if a differently named product was offered.

 

[corabell]

Thank you again to everyone for the suggestions and advice. I feel SOOO much better about this and am grateful to all of you sharing your journeys. You've helped us feel not so overwhelmed I'm glad I posted about this today, I hesitated because I felt like the Drs. knew best and if they weren't concerned, then maybe I shouldn't be, but something just didn't feel right.
I'm pretty disappointed in the medical system and the fact that we had to say the words Heparin for them to do anything. I told him to call and leave a message asking whether he should be using something until his INR was good, that way it was on record that he at least asked. He's also going to bring it up at his post op appt this week to find out why they didn't seem concerned and what we can do if this or something similar happens again.
So he was given Lovenox (Enoxaparin) 80mg, 1 shot every 12 hours for 4 days. Bridging was something I didn't look up or really know anything about so I have some learning to do. Do you guys think this was the best thing at this point, seems like it's at least in the forward direction?
Thanks for the links and blog posts. I will be downloading the INR chart and reading ALL of them, also looking at monitors!