Irregular INR on warfarin

[mom2angel]

I have been on an anticoagulant since having an artificial mitral valve put in in 1982. My INR stayed pretty regular for over 20 years. In 2007, when pregnant with my son, my INR started to fluctuate a lot. It has been all over the map since then. I am thinking that 2007 was around the time they switched me from Coumadin to Warfarin. I know the drugs are supposed to work the same, but I'm wondering if that is what's causing the fluctuations. Today it was 7.3. Oops! Has anyone ever noticed a difference between Coumadin and Warfarin? Your answers would be greatly appreciated. I checked into switching back today, but the cost difference is pretty high. I plan to make some calls to insurance and the Dr. tomorrow to see if we can't work something out. Thanks for any advice you have.
Jill

 

[dick0236]

I switched from Coumadin to Warfarin 15-20 years ago with no issues. I have noticed some small issues between warfarin brands......but nothing that would produce a 7.3. Have you, by mistake, doubled up on your dosage? What is your normal INR range? What is your normal warfarin dose? Are you on any anti-biotics? I'd talk to my doc ASAP as a 7.3 is not good.

 

[DachsieMom]

Jantoven is another generic of warfarin. My insurance co switched me to that for a bit. It was the same price as Warfarin. Perhaps give that a shot? I also found my INR erratic lately, as is my sister's (we both have st Jude mechanical with warfarin). - thought maybe it was the crazy heat!

 

[pellicle]

Hi

I have been on an anticoagulant since having an artificial mitral valve put in in 1982. My INR stayed pretty regular for over 20 years.

so you're obviously experienced

In 2007, when pregnant with my son, my INR started to fluctuate a lot. It has been all over the map since then.

that's a long time to be irregular.

I'll ask some questions in a minute...

I am thinking that 2007 was around the time they switched me from Coumadin to Warfarin. I know the drugs are supposed to work the same

well no they don't. Its well known in Australia that the do not and its well know that you don't go switching brands. There are two issues:

• the actual amount of warfarin in a (say) 5mg tablet may vary from maker to maker
• the mix of the enantiomers R and S (mirror images of each other) varies from maker to maker and that has a profound effect on your INR

but I'm wondering if that is what's causing the fluctuations

it could be a number of things ... are you taking any other drugs? how often are you testing? are you self testing?

if you wanted to work with me on your data I can perhaps come up with some answers

 

[QuincyRunner]

Jill,
Following my mitral valve replacement with a mechanical valve in 2011 I was on Warfarin for about six months and was unable to stabilize my INR. One of my doctors, as well as my pharmacist, suggested that I try the name brand, Coumadin, as a last resort. Almost immediately my INR stabilized and has been pretty steady ever since. Despite the huge difference in price with my insurance ($50.00 per month vs. about $4.00) I will stick with Coumadin for the rest of my life. I was told, and now believe, that even though the active ingredients are the same, the fillers used in the generics can vary with measurable and varying effects on the INR.

 

[mom2angel]

Thanks for the responses everyone. My current dose is 12.5mg/13mg. I alternate these every other day. My range is 3.0-3.5. I am currently taking an antibiotic. Please don't throw me under the bus for this...or do...haha. I'm taking one that was leftover in the medicine cabinet. I currently have a UTI that I'm trying to clear up on my own. I know, not smart! Because of the 7.3, I am no longer taking this. If I can't clear it up in a week, I'll go to the Dr. and let him prescribe a new antibiotic. Also, I drank a lot of cranberry juice over the last 3 days trying to get rid of the infection. I also think that might have affected the INR. But, these things have only been going on for about 3 days. My INR has been off for 10 years. About 3 years ago, I was at 9.2. That was my highest. I wasn't doing anything different then. Sometimes, it'll be 1.9 or 1.2. Sometimes 5.1. I have no idea why it jumps around.
I do not self test. I have it drawn through the arm in the lab. They told me to skip my dose tonight and recheck in the morning. I ate broccoli twice today and am hoping for a good result in the AM. Thanks again. I'll research the Jantoven too. Thanks for that suggestion.

 

[mom2angel]

I asked about this in a facebook group that I'm in. The group is a fan page for a band, but people talk about everything. One lady just said she has worked in a cardiologists office for 16 years and has seen the issues with warfarin. She said the generic drugs have a larger level of variance and they have seen it throw a lot of people's INRs off. Honestly, my cost difference isn't overwhelming. It would be $180-$270/mo versus $10-$15 I currently pay. That's a lot more than I want to pay, but if it gets me back to normal, and I can do less blood draws, it would probably be worth it. QuincyRunner, thanks for your response. Glad to hear that you had the same results I have had. I'll make it my mission to switch back to Coumadin.

 

[pellicle]

Hi

here are your problems:

I am currently taking an antibiotic. Please don't throw me under the bus for this...or do...haha.

always ... repeat always monitor INR closely when you begin antibiotics ...

which is why you should self test ... what you are describing is all the reasons why the once a month arm draw is not going to work ...
next

... Also, I drank a lot of cranberry juice over the last 3 days trying to get rid of the infection.

cranberry juice will not influence your infection but does make your INR change, so the answer is know your drug, and ... again ... self test


if you don't want to come to harm take your INR seriously and self test ... better yet, self administer. These old ideas of "once a month testing" are archaic and wrong. Better yet, self testing is not doing long term harm to your veins and is not anywhere near as inconvenient as lab draws.

the ball is in your court - self test for better outcomes ... better still : doing it on your own is cheaper.

 

[pellicle]

I asked about this in a facebook group that I'm in. The group is a fan page for a band, but people talk about everything. One lady just said she has worked in a cardiologists office for 16 years and has seen the issues with warfarin.

classic ... if I had a buck for every doctors office secretary who thought she was a Doctor ... but has done no studies herself and isn't probably on warfarin ...

 

[mom2angel]

Thanks pellicle. I did self test for awhile a few years ago. But I quit, because it was actually cheaper for me to do it in the lab since it was only once a month. The self testing company was making me do it every 2 weeks which cost me more in the long run. So, I was being cheap and chose to go back to the old fashioned lab. Now that I don't work across the street from the lab anymore, I've been thinking about going back to self testing. Right now, it's not on the top of my priority list. My kids and family life keep me so busy that my own health is not at the top of the list, hence the infection and not keeping on top of my INR. I'm one who likes to get it drawn less often so I don't know when it's off. I know that's horrible, but it's true. I've been on it since I was 2 years old, so it's always been a way of life for me, and not something I take serious enough. Don't rip me abart for that please..haha. But, I'm finally at a point where my kids are a little older (9 and 4) and I have a little more free time to start taking better care of my health. My goal is to get back on the Coumadin and off Warfarin soon. In 20+ years on Coumadin, I never had the problems I've been having in the last 9 1/2 years on Warfarin. I appreciate your comments. They are helpful.
I realize the gal that worked in the cardiologist office wasn't a doctor but it was also helpful to me to hear that she has seen patients INRs fluctuate on Warfarin. Makes me feel like I'm not alone in this . Thanks again pellicle. Hope all is well with you. School starts tomorrow for us, so we are calling it an early night.

 

[mom2angel]

Pellicle, what exactly does cranberry juice do to an INR? I've never found an answer to that question. I'm assuming it can raise it. Thanks. The funny thing is that I just learned from a coworker about 7 years ago that your diet can affect your INR. Her Dr. told her. In 1982 no one ever said anything about diet to me. Every other Dr. probably assumed I knew this, so they never said anything ever. So, I have never watched my diet before. Now that I know, I try to eat the same amount of green veggies each week to help regulate it. I also don't drink much alcohol, but that's more of a lifestyle thing for me.

 

[pellicle]

Hi

Pellicle, what exactly does cranberry juice do to an INR? I've never found an answer to that question..

I'm not sure and I don't think anyone yet is ... for instance we know it has an effect:

This from 2011
http://www.ncbi.nlm.nih.gov/pubmed/21364039

[h=4]CONCLUSIONS:[/h] Our case report describes INR elevations in a patient previously stable on warfarin after ingestion of cranberry juice cocktail daily for several days. This elevation occurred on 2 separate occasions, which distinguishes our case from other published literature.

but we don't know the mechanism as this 2010 review failed to clarify how
http://www.ncbi.nlm.nih.gov/pubmed/20865058

My own experimentation on greens has not yeilded any clear results ... even when working with Gym Guy juicing a kilogram of spinach did not make as much effect in his INR as he thought it may.

But as I always say ... measure twice cut once.

As for fluctuations yeah its more common than people think just to give you an idea of my own here is a graph from 2015 ... note that I took action on a high INR trend which had I not I don't know how high it may have gone ... but you'll see also that it resumed normality fairly soon. Had I been measuring monthly then it may have been harmful.

 

[pellicle]

PS mom2angel

read this thread:
http://www.valvereplacement.org/foru...-python-moment

and watch out for grapefruit juice (with most medications) too...

Lastly I really like the wording of this source:
http://pharmacyservices.utah.edu/alerts/697.html
[FONT=&quot]Recommendations for educating patients about warfarin and cranberry consumption include:[/FONT]

• Drinking 1-2 glasses of cranberry juice daily is safe in patients taking warfarin.
• Consuming larger amounts of cranberry products or for a longer duration has not been fully evaluated.
• Consult a healthcare professional before making significant changes in cranberry consumption.

wise stuff ... but the last point still worries me that the Yanks haven't caught on

• Continuously monitor for signs of bleeding while taking warfarin.

self testings works ... don't wait till you see blood in your urine ... its not 1970 anymore, so what it should read is:

• Regularly monitor your INR with a self testing unit

 

[mom2angel]

That's a great graph. I don't have a graph, but I write mine in my planner each time it is taken. I can go back and list the last few just for example. I'll list all of 2016, then you'll also see that I don't do it as much as instructed. oops! Dec 30, 2015--3.3. March 17, 2016--3.8. March 25--3.5 Cardioversion was done on April 15. They drew it in hospital, but its not written down. It was probably 3.2ish May 20--5.2. May 24--3.2. June 2--3.7 June 15, 4.3 July 14--2.2 May 16--7.3. So you can see, I don't go in nearly as often as I should. Am I setting myself up for problems? Probably, but that's my issue right now. I definitely should start being better about that. I'm a busy, tired mom that is putting everyone above myself like most moms do. But I also have a heart issue that's been with me a long time. I'll try to do better from now on. Thanks for showing me your graph and your advice. My range is 3.0-3.5 4 out of the 10 draws I listed were within range, if the hospital one was in range. So I guess i was in range 40% of the time. Not good stats, but it could be worse. But, that's why i want to change things and have them like they were for over 20 years. Easy..isn't that what we all want?? Lol

 

[Freddie]

FWIW Cranberry juice is known for assisting in healing & avoiding UIT infections.

 

[pellicle]

Hi

.... I don't have a graph, but I write mine in my planner each time it is taken.

that's often just as good ... a book or a journal that you keep specifically for that is a great habit

Easy..isn't that what we all want?? Lol

well I want it all ...

well that's not true ... I just want what I can't have (but which I once did).

 

[pellicle]

Hi

FWIW Cranberry juice is known for assisting in healing & avoiding UIT infections.

I guess I'm just skeptical of most herbal treatments (although I do know well that most drugs originated from a herbal source)

Because I knew nothing on the topic I thought I'd google it
http://www.ncbi.nlm.nih.gov/pubmed/19441868

At present, there is no evidence that cranberry can be used to treat UTIs. Hence, the focus has been on its use as a preventative strategy. Cranberry has been effective in vitro and in vivo in animals for the prevention of UTI. Cranberry appears to work by inhibiting the adhesion of type I and P-fimbriated uropathogens (e.g. uropathogenic E. coli) to the uroepithelium, thus impairing colonization and subsequent infection.

so the avoiding bit for sure seems like a valid point.

If one was inclined to drink that bitter tasting stuff as a prophylactic then I'd say follow the advice from the Utah University page and drink 1~2 glasses ... if you desire more, then check its influence on INR.

None the less I still advocate for weekly testing and self testing as beneficial and reducing the possibility of an out of control INR

 

[mom2angel]

Freddie, I've always had good luck clearing up UTIs with cranberry juice. This time, I'm losing the battle. My stress level has been high lately, and I know that's the cause of the infection. Hopefully it'll clear up soon.
Pellicle, I was reading on another post where some of you were talking about how staying with the same brand of warfarin is the best idea. My small town pharmacy sends me whatever they have. So, I am constantly taking a mixture of different brands. Right now, some of my bottles say TEVA pharmacies and some say Citron Pharmacies. I have no idea what the actual brand name is. They're obviously different, because some pills are round ne some are kind of oval or pill-shaped. However, I have decided I need to go back on the name brand Coumadin to try that. I will be calling the Dr. after 8am today to try to get a script filled for it. You've all been a big help. I'll let y'all know how it goes.

 

[mom2angel]

Talked to my cardiologist's nurse today and got a gameplan. She's going to talk to the Dr. and see if he will write up a script saying that the name brand seems to work better for me. If insurance doesn't want to cover it, I will buy a 3 month supply and pay out of pocket. I'll take it for 3 months and hope it clears things up. If it does, then they will file a rebuttal with the insurance company. In the back of my mind, I'm wondering if maybe this won't work. I'm tired of my INRs being all over the place for the last 10 years, but I honestly don't know what to do. We are just going to follow the plan, and see what happens. Thanks all

 

[pellicle]

Hi

...In the back of my mind, I'm wondering if maybe this won't work. I'm tired of my INRs being all over the place for the last 10 years, but I honestly don't know what to do. We are just going to follow the plan, and see what happens. Thanks all

I think that's a good first step ... dealing with unknowns is always like that ... tick them off one at a time.
Just make sure to factor in things like antibiotics and even other "drugs" which you may not think of as drugs at the time ... like voltaren

best wishes