INR

[Emmapenny]

Hiya

Just after some opinions regarding my sons INR.

He’s been on warfarin for 4 months now and he seems quite steady. His range is 2-3.
They adjusted him to 6.5 mg and since then he’s sat at between 3 and 3.3 for about 3 weeks. So he’s had 3 readings out of range in that time, even though they’re not that high they are still out of his range.

They’ve kept him on the same dose as they’d rather he was slightly out of range higher than lower - which i do understand.

But I think I would feel better if he was nearer to 2.5 than 3.5 . When I spoke to the nurse about it and said he’s out and about living his life and being a teenage boy so i wonder if it would be better being lower she said his risk is being on warfarin regardless and being at 3.3 is no worse than being at 2.5.

So I don’t completely disagree with the above and I have seen the chart that pellicle has shared in the past which shows where the risks increase etc but I don’t see how being at 3.3 is the same at 2.5. Am I justified to feel a lower range would be better for him?

So I guess I just wanted to hear from those who self dose if they would change their dose in this scenario.

Hope that makes sense!

 

[pellicle]

But I think I would feel better if he was nearer to 2.5 than 3.5

Ageed, and as you say his range is 2-3, meaning his target is 2.5 (this is now the more modern way of thinking about it).

That's also the guidelines for aortic position without previous history of stroke or TIA.

Basically they should titrate his dose to be in target.

The risks of INR related are low at this INR, but if he has any other injury (like fell) then that injury will be exacerbated by the increase in bleeding cased by the higher INR.

I always follow the fundamental rule of aim for 2.5 with the caveat of clinically significant difference. A clinically significant difference would be (and its fuzzy) 0.2 either side of the target. So for instance if I saw 2.3 I wouldn't adjust nor would I adjust if I saw 2.7

I will adjust if I see 2.2 and I will adjust if I see 2.9

HTH

 

[pellicle]

PS:

note the wordings in this document (italics mine)

European Heart Journal (2021) 00, 172
ESC/EACTS GUIDELINES
doi:10.1093/eurheartj/ehab395
2021 ESC/EACTS Guidelines for the management of valvular heart disease

Table 10 Target international normalized ratio for mechanical prostheses​

then from chapter 11 on prosthetic valves

11.3.1.2 Target international normalized ratio​

Target INR should be based upon prosthesis thrombogenicity and​

patient-related risk factors (Table 10)​

 

[Emmapenny]

They didn’t adjust his dose and he’s now 3.9 today.

Its not about being proved right or wrong but I do feel like I’m already getting a grip on this and we aren’t that far down the road.

I don’t suppose they’ll let me manage his doses , especially as he’s a child, but I’m now a little bit lost as to what I do when I don’t agree with their dosing next time.

 

[Superman]

I don’t recommend this strategy. But I came to a point where I did what I felt was right and when I was back in range, I told them what I had taken so my chart was correct. After a couple times, the clinic and I became better partners. If I’m out of range, we’ll talk about why I think that might of happened. Basically, I’ll tell them if I was sick or taking meds or changed diet. Then we’ll talk about dosing. They’ll suggest. I may agree or I may counter. Sometimes they agree with my counter offer and sometimes I’ll try their suggestions. But it is in part because I’ve been at it 32 years and many of them have only have a couple years experience and a handbook (and I played that card a couple times in the past).

 

[tom in MO]

At 3.9 with a 2-3 range, you are 2x the low end. I'd stop talking to the nurse and speak to the physician.

I manage my own warfarin, 2-2.5 range, and I drop my warfarin level to get into range when I hit about 2.8 and always when I hit 3.

 

[LondonAndy]

I don’t recommend this strategy. But I came to a point where I did what I felt was right and when I was back in range, I told them what I had taken so my chart was correct. After a couple times, the clinic and I became better partners. If I’m out of range, we’ll talk about why I think that might of happened. Basically, I’ll tell them if I was sick or taking meds or changed diet. Then we’ll talk about dosing. They’ll suggest. I may agree or I may counter. Sometimes they agree with my counter offer and sometimes I’ll try their suggestions. But it is in part because I’ve been at it 32 years and many of them have only have a couple years experience and a handbook (and I played that card a couple times in the past).

I realise we can't advocate for others to do this, but I completely agree, and it is what I do too.

In my case, with a therapeutic range of 2.5 to 3.5, I aim to be 3.0 to 3.4. This is because experience has shown:

1. Having a cold can cause quite a dramatic drop in my INR, even before I know I have got the cold, and so I want to allow sufficient headroom for that drop to happen and me still be in range.
2. My meter fairly consistently reports results 0.1 or 0.2 higher than that at a clinic test, and so when I am 3.4 on my meter I think I may actually be 3.2. Both readings are fine, of course, but it comes back to my point 1.

As @Emmapenny says, I would be less worried about being slightly above range than going below 2.5, and so if I go above range I reduce my dose my 1mg or so for a day or two, testing again in 3 or 4 days to see what effect it has had, and repeat if necessary. Frankly I don't tell my clinic about these minor "course corrections" unless I have a sustained period of deviation from the normal, and then it is great to discuss it with them.

 

[pellicle]

but I’m now a little bit lost as to what I do when I don’t agree with their dosing next time

as I see it you have two choices:

1. strongly advocate and remind them of their duty of care
2. become self sufficient and monitor and dose yourself

perhaps some blend of the above is possible, but as always knowing what to do in advance takes a "situation" from being panic to just another stone hop.

Lastly I'd say that 3.9 isn't "threatening" but you should put a pause on any soccer or football activities till its back under 3

have we worked together before? I'm not seeing any old sheets in my "Drive". Reach out if you wish to

 

[pellicle]

Frankly I don't tell my clinic about these minor "course corrections" unless I have a sustained period of deviation from the normal, and then it is great to discuss it with them

a method I advocate ... do what you want, apologize later (if needed). Has been interesting and empowering in the past.

 

[pellicle]

After a couple times, the clinic and I became better partners.

that's a good outcome.

But it is in part because I’ve been at it 32 years and many of them have only have a couple years experience and a handbook (and I played that card a couple times in the past).

from what I've experienced (not in the USA, but so far half this conversation isn't) the hanbook is minimal, the staff may not have any actual durable experience with a single person (and cover clients more or less randomly).

I'm 99% convinced that I do better with myself than any clinic I've dealt with.

PS I strongly feel that in the main clinics de-capacitate and infantilise their clients.

 

[carolinemc]

I realise we can't advocate for others to do this, but I completely agree, and it is what I do too.

In my case, with a therapeutic range of 2.5 to 3.5, I aim to be 3.0 to 3.4. This is because experience has shown:

1. Having a cold can cause quite a dramatic drop in my INR, even before I know I have got the cold, and so I want to allow sufficient headroom for that drop to happen and me still be in range.
2. My meter fairly consistently reports results 0.1 or 0.2 higher than that at a clinic test, and so when I am 3.4 on my meter I think I may actually be 3.2. Both readings are fine, of course, but it comes back to my point 1.

As @Emmapenny says, I would be less worried about being slightly above range than going below 2.5, and so if I go above range I reduce my dose my 1mg or so for a day or two, testing again in 3 or 4 days to see what effect it has had, and repeat if necessary. Frankly I don't tell my clinic about these minor "course corrections" unless I have a sustained period of deviation from the normal, and then it is great to discuss it with them.

Range for you should be 2.5 to 3.0. But medical personnel take it a different direction. Yes, sick with cold or flu can affect INR. Also, antibiotics can also affect the Protime. Do not sweat the .1 difference. And also, exercise can affect the INR also. Just discuss with the clinic when INR is not in normal range at home. Welcome for the share.

 

[Emmapenny]

as I see it you have two choices:

1. strongly advocate and remind them of their duty of care
2. become self sufficient and monitor and dose yourself

perhaps some blend of the above is possible, but as always knowing what to do in advance takes a "situation" from being panic to just another stone hop.

Lastly I'd say that 3.9 isn't "threatening" but you should put a pause on any soccer or football activities till its back under 3

have we worked together before? I'm not seeing any old sheets in my "Drive". Reach out if you wish to

We’ve not officially worked together but I’ve read and re read all your blogs numerous time. I like to read up on things until I understand and they’ve been so helpful - thank you!

 

[thomas999]

Here are my last five INR checks, starting with the most recent at the top descending to the least recent test. I sort of hope I could get the mechanical valve taken out and a biological valve put in, not only for the blood thinners and thinness inconsistencies, but also for other reasons as well. I don't know why it fluctuates up and down like it does, but probably has to do with diet. I had a pretty good paper cut on a finger of my left hand, and had the darndest time of getting it to clot.

26.4
2.2

36.3
3.0

35.0
3.0

26.4
2.3

30.5
2.7

 

[pellicle]

Here are my last five INR checks, starting with the most recent at the top descending to the least recent test.

I sort of hope I could get the mechanical valve taken out and a biological valve put in, not only for the blood thinners and thinness inconsistencies, but also for other reasons as well.

what would that be?

I don't know why it fluctuates up and down like it does, but probably has to do with diet.

Diet is unchanged, if you eat differently because of the valve then someone has misinformed you.

I had a pretty good paper cut on a finger of my left hand, and had the darndest time of getting it to clot.

I wrap with tissue and then some sticky tape if nothing else is available, usually a few minutes pressure helps. I also use a bit of superglue ... but then this was what I did even before I was on warfarin. If you INR was around 3 then that will make things worse

26.4
2.2

36.3
3.0

35.0
3.0

26.4
2.3

30.5
2.7

That's not particularly helpful without dates and daily doses. Working weekly doses hides details too. I don't even know what the frequency of testing is here.

But thanks for posting

PS: I don't know if it helps but this is what I do weekly
https://cjeastwd.blogspot.com/2015/10/managing-my-inr-example.html
notice that I record dose daily; because I take it daily and I take it the same dose every day of that week, its important to take as close to the same dose every day (which thinking in weekly doses obscures). My body doesn't have a weekly cycle and the disposal system of the body doesn't work in weeks either. The study of pharmacy (pharmacology) works in understanding half lifes of drugs which aren't weekly either, they use daily or if its fast then hourly.

Without understanding these things you will remain befuddled on how to properly work with the drug and understanding its reaction within you.

Have a read of that blog post and then some of the articles it links to.

Best Wishes

 

[ATHENS1964]

I also use super glue for medical use, however.
https://morethanjustsurviving.com/super-glue-for-cuts/

 

[Warrick]

If it was me, I would adjust his dose and not tell them if you think they would be averse to this.
I don't know what pill sizes you have and from what I understand they vary country to country, but it sounds like he probably needs a 1/2 mg less a day or there abouts.
I don't split tabs I just alternate between currently 11mg and 12 mg day to day to give me 11.5mg which is my current dose, I started way back on 9mg a day so expect his dose to change over time.
Being only 15 now and having the next 50+ years in front of him on warfarin (unless meds change) learning and managing his own dosing I would say is a necessity.
Self-management is empowering and keeps you in the driver's seat, it becomes second nature over time.
The people managing his dosing are not going to be affected if his INR is not right, he is so take the bull by the horns as much as you can I reckon.