INR won't budge

[corabell]

Hello again Hope everyone is doing well. I have a question about my husband's INR and Warfarin. He's coming up on 1 year anniversary this month of the replacement of a bicuspid valve with an On-X valve. He had a rough start with Warfarin trying to get in range but eventually it got worked out to average about 2.2 to 2.5.
Then at the beginning of December INR started dropping, 1.7 to 1.9. Dose was increased after each low lab number from 8.75 to 9 to 9.25 to 9.5 daily, today's lab results were 1.5. Dose was upped to 10mg starting today. I was just wondering if anyone knows of reasons we aren't thinking of that INR would continue to drop even though the dose is being increased.
No major changes in diet, he eats salad and vegetables every day which he has always been that way. No supplements. No change in exercise. No other med changes, he's still only on aspirin and metoprolol daily. We were even considering he got a bad batch of warfarin so he started using the other mg tablets that he had on hand to see if it went back and it hasn't.
I'm just not sure why he's had such a hard time with this stuff, he never misses a dose, has pill boxes filled every week, does everything he thinks he should? It's frustrating. The low INR is scary, the only reason I guess nobody is freaking out is because he has an ON-X but we fought hard to get his range changed from 1.5 to 2.0 to 2.0 to 3.0 because he didn't feel comfortable going that low. (we no longer use the Coumadin clinic, it was a nightmare.) Anyway, suggestions or tips or does this kind of thing just happen and you have to find a new higher normal?

 

[csigabiga]

I am far from an expert on this, but are you measuring weekly (or twice a week until stable) at home? Seems like thats the only way to account for differences.

 

[corabell]

I am far from an expert on this, but are you measuring weekly (or twice a week until stable) at home? Seems like thats the only way to account for differences.

He has a machine to test at home and he gets labs done as well. Home machine and lab are usually very close. He was testing once a week at home and labs were once a month until he started dropping, now labs are every 2 weeks to monitor the dose changes they give him. Lab today was 1.5.

 

[tom in MO]

There are some mysteries about INR and warfarin. If it was science, they would be able to just calculate the correct dose. A change from 8.75 to 10 is only 14%. Not really a lot. In the past my dose has changed from 5.5 to 4.5 w/o known reason, which is 22%.

How does he get 0.25mg changes in dose? My smallest change is 0.5mg or half a 1mg tablet.

 

[corabell]

He has 1mg, 2.5mg, and 3 mg tabs. So it's been a pain but using a combo of them to get the adjusted doses.

 

[LondonAndy]

I am at a loss to help with why the sustained drop in INR, and would not normally suggest a significant change in dose but given how low he still is have you considered going to 12mg/day for a while, (I think he is currently on 10mg?) and test every 3 days (the typical time Warfarin takes to take full effect in the blood) and see what that does?

 

[corabell]

I am at a loss to help with why the sustained drop in INR, and would not normally suggest a significant change in dose but given how low he still is have you considered going to 12mg/day for a while, (I think he is currently on 10mg?) and test every 3 days (the typical time Warfarin takes to take full effect in the blood) and see what that does?

Thank you, I will suggest a slightly higher mg to him. He is to start 10mg tonight, the lab result of 1.5 was this morning. I tend to agree with maybe just starting a bit higher to see where it goes since these small changes have not been doing anything. I just didn't know how much was too much to jump all at once. Either way, he'll re-test here in 3 days.

 

[pellicle]

Hi

I guess the first thing to say is that warfarin is an atypical drug in some ways. Its key to remember that with ALL DRUGS the reason we take them is for the effect. We don't take them to take a number of milligrams.

In the main most drugs have a pretty wide range of tolerance (that's a discussion right there) but with warfarin we have learned in the last 80 years of using it that a tight range of tolerance is ideal to reduce the sideffects. We are luck with warfarin that we have a convenient measurement (called INR) that allows us to perfectly tune that to us, so therefore the only thing that should determine dose is the INR reading.

Anyway, suggestions or tips or does this kind of thing just happen and you have to find a new higher normal?

it does and sometimes its predictable and sometimes its not

He has 1mg, 2.5mg, and 3 mg tabs. So it's been a pain but using a combo of them to get the adjusted doses.

well perhaps I can help you with that using this spreadsheet (attached as a zip file). To use it

1. download the zip
2. extract the file to your documents area
3. enter data in it starting with the smallest fraction first
4. the splits are found in clicking the formula

Lets look at an example

to get 9mg keep adding (put + after you click each of the cells that represent your choice) until "remain" is 0
click on the combo cell to see the cells highlighted denoting the combination of splits you need.

I'd also request from your doctor that you get 5mg tablets too. I personally have 1, 3 and 5mg tablets.

Thank you, I will suggest a slightly higher mg to him. He is to start 10mg tonight, the lab result of 1.5 was this morning.

that's too low and you should move him up as a priority. He should be over 2.0 for maximum safety. Step up in increments but I could probably help you better if you gave me his previous daily dose and the typical INR that resulted in.

Feel free to reach out by PM if you want me to whap up a sheet for you, walk you through it and that will help you manage him better and keeps good records.

Best Wishes

 

[carolinemc]

Hello again Hope everyone is doing well. I have a question about my husband's INR and Warfarin. He's coming up on 1 year anniversary this month of the replacement of a bicuspid valve with an On-X valve. He had a rough start with Warfarin trying to get in range but eventually it got worked out to average about 2.2 to 2.5.
Then at the beginning of December INR started dropping, 1.7 to 1.9. Dose was increased after each low lab number from 8.75 to 9 to 9.25 to 9.5 daily, today's lab results were 1.5. Dose was upped to 10mg starting today. I was just wondering if anyone knows of reasons we aren't thinking of that INR would continue to drop even though the dose is being increased.
No major changes in diet, he eats salad and vegetables every day which he has always been that way. No supplements. No change in exercise. No other med changes, he's still only on aspirin and metoprolol daily. We were even considering he got a bad batch of warfarin so he started using the other mg tablets that he had on hand to see if it went back and it hasn't.
I'm just not sure why he's had such a hard time with this stuff, he never misses a dose, has pill boxes filled every week, does everything he thinks he should? It's frustrating. The low INR is scary, the only reason I guess nobody is freaking out is because he has an ON-X but we fought hard to get his range changed from 1.5 to 2.0 to 2.0 to 3.0 because he didn't feel comfortable going that low. (we no longer use the Coumadin clinic, it was a nightmare.) Anyway, suggestions or tips or does this kind of thing just happen and you have to find a new higher normal?

Need to ask the doctor about the range and what he can do to get it stable. Good luck in getting info from his doctor.

 

[Mister_James]

Hello again Hope everyone is doing well. I have a question about my husband's INR and Warfarin. He's coming up on 1 year anniversary this month of the replacement of a bicuspid valve with an On-X valve. He had a rough start with Warfarin trying to get in range but eventually it got worked out to average about 2.2 to 2.5.
Then at the beginning of December INR started dropping, 1.7 to 1.9. Dose was increased after each low lab number from 8.75 to 9 to 9.25 to 9.5 daily, today's lab results were 1.5. Dose was upped to 10mg starting today. I was just wondering if anyone knows of reasons we aren't thinking of that INR would continue to drop even though the dose is being increased.
No major changes in diet, he eats salad and vegetables every day which he has always been that way. No supplements. No change in exercise. No other med changes, he's still only on aspirin and metoprolol daily. We were even considering he got a bad batch of warfarin so he started using the other mg tablets that he had on hand to see if it went back and it hasn't.
I'm just not sure why he's had such a hard time with this stuff, he never misses a dose, has pill boxes filled every week, does everything he thinks he should? It's frustrating. The low INR is scary, the only reason I guess nobody is freaking out is because he has an ON-X but we fought hard to get his range changed from 1.5 to 2.0 to 2.0 to 3.0 because he didn't feel comfortable going that low. (we no longer use the Coumadin clinic, it was a nightmare.) Anyway, suggestions or tips or does this kind of thing just happen and you have to find a new higher normal?

So a little tea chat. There is no need to fight with medical practioners. Aortic valve mechanical INR is 2-3 and you can aim at 2.5 and you just tell your doc that's the range YOU want to be in and is there a problem?
Second, INR is an art form not a science. You look at the trends not just one number. If you are trending towards your goal you maintain the dosage if not adjust 10-15٪ of your weekly dose.

 

[corabell]

Thank you for the zip file pill split, that should come in handy! He took 11mg last night and will take that until he tests again in a few days to see what that does.
As for getting info from a doctor...yeah luck is what you need sometimes apparently. We don't like to fight with medical practioners, lol. The clinic wouldn't listen to us. In fact they got mad he had a home machine and they said they wouldn't adjust meds or retest labs sooner just because some random machine started showing a low INR. They only changed his INR range on his records after I questioned the validity of the studies they were spouting off about the ON-X valve being ok for low INR, (I had read the report and found some of the data a bit "off" with regards to how they changed people from group to group). But really none of that should have mattered, he wanted his INR higher and it was being fought. It's not like he wanted an outrageous change, just didn't want a 1.5 on a test to be OKAY by them.

 

[Chuck C]

The clinic wouldn't listen to us. In fact they got mad he had a home machine and they said they wouldn't adjust meds or retest labs sooner just because some random machine started showing a low INR.

They are fools. I'm glad to hear that you kicked that clinic to the curb.

 

[pellicle]

Hi

Thank you for the zip file pill split, that should come in handy!

welcome ... I'm always slow with stuff like that ... probably too many years in IT with calculators and spreadsheets right there ...

He took 11mg last night and will take that until he tests again in a few days to see what that does.

let us know what he tests

.... We don't like to fight with medical practioners, lol.

but sometimes that happens ... change doctor if you can

The clinic wouldn't listen to us. In fact they got mad he had a home machine and they said they wouldn't adjust meds or retest labs sooner just because some random machine started showing a low INR.

some random machine ... what's the betting a parent company is milking other patients for billing an insurance company $60 a test for someone using a coaguchek.

They only changed his INR range on his records after I questioned the validity of the studies they were spouting off about the ON-X valve being ok for low INR, (I had read the report and found some of the data a bit "off" with regards to how they changed people from group to group).

agreed ... and a few other things

But really none of that should have mattered, he wanted his INR higher and it was being fought. It's not like he wanted an outrageous change, just didn't want a 1.5 on a test to be OKAY by them.

I wouldn't want 1.5 either ... indeed in the PROACT study median INR for the low intention to treat group was 1.89 IIRC

Ftards

reach out if I can do anything more.

Best Wishes