I've crossed the line into severe and need to make a decision

[Chuck C]

Sorry to hear Chuck. That's high! They're not making it easy for you! Definitely agree one must be own advocate, question and challenge everything.
Easy to get standing order at Quest from your PCP. I've had one since getting home. You should test every 2 to 3 days now until INR is closer to target. With the massive K influx, amiodarone, and holding Warfarin, you're going to see variability for awhile. Hang in there!

INR from 10am testing this morning just came in: 2.4!
Very good news.
Will actually be testing every day for awhile, because there are opposing forces at the moment in my system. I am still on Amiodarone, which amplifies the effect of warfarin, but at half the dose, and have have 2.5mg of k1 and 2.5 of k2, which were both taken yesterday, still pushing down the effects of warfarin. In fact, given that I was INR 2.4 about 3 hours ago, my INR is almost certainly below that now. But, still there is margin before I get in any trouble.

Just dosed 3mg warfarin now and will be interesting to where we are at Saturday morning. Which will have more impact- vitamin k or amiodarone? From what I could find online, vitamin K influences INR for about 24-48 hours. So, it did its job well, and hopefully will not be in the mix soon. From then it is just a matter of finding the right warfarin dose that keeps me in range, while being amplified by a now lower dose of amiodarone. I was on 800mg amiodarone and they switched me to 400mg as of today.

Lots of testing in the next few days, but things are under control.

 

[Chuck C]

INR has been reduced from 9.7 to 2.4 in the last 24 hours with vitamin k1 and vitamin k2 therapy

I wish that the pharmacist and the Coumadin Clinic doctor had read this study linked below and watched my INR more carefully when amiodarone was added to the mix. I'll say it a thousand times: you need to be your own advocate. This could have easily ended tragically had I listened to the clinic and not worried about testing for another few days. Instead, I suggested that they send orders for an INR test to Quest for me so that I could head straight to Quest to get tested. They were happy to do so. They are human and things happen. They are good people and did what needed to be done in getting me the antidote.

https://www.aafp.org/afp/2002/0415/...ve shown that,increasing the risk of bleeding.

" The authors state that with amiodarone dosages of 400, 300, 200, or 100 mg per day, the warfarin dosage should be reduced by 40, 35, 30, or 25 percent, respectively. Minor episodes of bleeding occurred in 12 percent of the study subjects. "

Keep in mind, they had me on 800mg/day of amiodarone, twice the top tier of the linked study. I am now on 400mg/day.

 

[pellicle]

INR has been reduced from 9.7 to 2.4 in the last 24 hours with vitamin k1 and vitamin k2 therapy

I would not underplay the significance of cessation of the amiodarone which would then allow your disposal system (Cytochrome P450) to do its job and pull out the warfarin levels. I'd keep an eye on it and I'd also re-continue your warfarin at about the previous dose levels.

wait:

I am now on 400mg/day.

are you still taking it?

Best Wishes

 

[Chuck C]

are you still taking it?

Yes. I skipped my dosage last night; was scheduled for 400mg.
Today they reduced me from 800mg/day amiodarone to 400mg/day amiodarone.

 

[pellicle]

Today they reduced me from 800mg/day amiodarone to 400mg/day amiodarone.

so if you're still taking it then its probably going to cause trouble. I'll be interested to follow this as its a good exemplar of the struggle between Vitamin K reversal and P450 impairment to the disposal rate of warfarin.

when is your next INR reading likely?

 

[Chuck C]

so if you're still taking it then its probably going to cause trouble. I'll be interested to follow this as its a good exemplar of the struggle between Vitamin K reversal and P450 impairment to the disposal rate of warfarin.

when is your next INR reading likely?

I'll be getting in at Quest tomorrow morning, in about 14 hours. There are several factors at work influencing my INR.
The last two readings, today at 10am at 2.4 at Quest, then again, just two hours later at Labcorp at noon- 2.2. The reason we did one at each was to get a quick read to see if there was any direction it was still headed, after the big vitamin K ingestions, and also to see which lab had the quicker turn around. Both companies, even with a rush order, had to get the samples to their main hubs in San Diego- one hour away. Quest did much better with results in 2 hours 15 minutes. Labcorp took 3:45.

Since at noon I was at INR 2.2 and probably still dropping, we dosed 4mg of warfarin.

Amiodarone reduced from 800mg/day to 400mg/day, it is still in my system of course and will tend to amplify warfarin effects. The literature suggests that, under normal circumstances, at 400mg/day amiodarone, 4mg warfarin would be about 6.7mg. But, of course, the circumstance is not normal and I still have lots of K1 and k2 in my system, with a half life of 27.5 hours. So, this will continue to have a downward effect.

As discussed, I would rather shoot a little high than to end up low. Very curious to see the number from tomorrow morning. Perhaps by that time vitamin K will not be much of an effect and I will be just dealing with warfarin and the effects that warfarin has on INR in the presence of amiodarone.

 

[user 15848]

Wish you all the best and that you recover soon, Get into SELF Test ,
lots of people here have postings about it, i have been doing it for 5 years,
Good luck

 

[Chuck C]

Wish you all the best and that you recover soon, Get into SELF Test ,
lots of people here have postings about it, i have been doing it for 5 years,
Good luck

Thanks
I’m buying one this week. I have always intended to self test but figured it would be after a month or so, because my surgeon’s office said that they like to coordinate that with the insurance company and can usually get insurance to pay for it. If I had advice this never would’ve happened at least it would not expect this high because I would have tested Tuesday and Wednesday realized early that something was causing INR to spike and made adjustments

 

[newarrior]

Chuck keep us posted..Thanks for the shares man !!) WE ARE HERE FOR YOU BROTHER !__

 

[Chuck C]

Chuck don't feel bad about not buying the machine before surgery. You've done a brilliant job pre-op and post-op + you did a lot of good preventative stuff as I've known you since January and your quest to stay healthy before you ever got surgery. Off topic but related to your brilliant post-recovery story. More and more my research leads me to believe that folks like yourself and me who are extremely healthy before surgery tend to bounce back quickly ..you're inspiring me. Like yourself I'm a fitness fanatic you know that I'm extremely compliant about medications I'm on a hardcore esselstyn vegan diet I'm good about taking a lot of other alternative type stuff I meditate Don't drink don't do alcohol again my diet is extremely tight and I'm seeing doctors constantly and doing a lot of Home Health Care a lot of screenings ..I think those of us who do that increase the odds in our favor of recovery post-op. I'll look forward to hearing your Coumadin stories as well as your recovery stories. Thanks again for inspiring us. good luck with the coumadin and the INR..

I agree that going into the surgery in good health, with good diet and regular exercise, probably significantly increases the chance of a good recovery and increases the likelihood of being back up in the saddle soon.

 

[newarrior]

I agree that going into the surgery in good health, with good diet and regular exercise, probably significantly increases the chance of a good recovery and increases the likelihood of being back up in the saddle soon.

It certainly can't hurt. Not just that but doing what the doctors tell you to do doing your screenings doing your meditation attending to your mental and psychological and spiritual part of your life taking medications or any alternative therapies that you believe are helping etc etc...

 

[Chuck C]

Update: Day 12 of recovery.

INR still low. In fact it dropped much lower: 8am test at Quest found INR 1.6. The vitamin K worked a little too well. Found out the info at 11am and immediately took 4mg of warfarin, with the guidance from the Coumadin Clinic guy assigned to my case.

Almost was unable to get it tested at Quest. The clinic sent the order in. I showed up Saturday with no reservation, as I always do. It will not work for me to make a reservation, which usually has to be a couple days out. So, I arrive 20 minutes before they opened to get a good spot in line- 3rd. Man opens the door and says Saturday is for appointments only. A few of the people walk away. I told him my situation- how it was urgent that we get an INR reading today, so that we know how to dose warfarin. I am happy to report that he was human and was able to get me in. So often people stick to their rules, regardless of the consequences, but he did not hesitate to help once he understood how urgent it was. It was very important, because over a 24 period I had gone from way over range to under range and no idea how to dose without an INR reading. Plus, tomorrow is Easter Sunday and no way to get tested.

I'm not too worried about the 1.6 INR. People get down that low all the time for elective surgery. Of course, it does put me at higher risk for thromboembolism, but we are now 12 hours past that point of 1.6 INR, and I have yesterday's 4mg of warfarin working for me, as well as today's 4mg. Hopefully much of the vitamin k has burned off. In the hospital, without interference from amiodarone, I found INR equilibrium alternating between 3mg and 4mg. Amiodarone amplifies the effect of warfarin. Still unknown how much the residual vitamin K in my system offsets this.

It will be interesting to see Monday's reading. I take this experience as a good one. It showed me that there is no need to panic if INR goes out of range- just get in back as soon as you can. I did not die when it went to 9.7, nor did I die when it went to 1.6, and those are probably not the high point nor low point of my swings.

Next week should be much more manageable and my Coaguchek xs arrives next Friday, so I will be much more in control of my own destiny. Great price on Ebay for a used one at $ 220- thanks Pellicle for steering me towards that auction!

 

[pellicle]

Pellicle for steering me towards that auction!

You are welcome.

 

[Unicusp]

Update: Day 12 of recovery.

INR still low. In fact it dropped much lower: 8am test at Quest found INR 1.6. panic if INR goes out of range- just get in back as soon as you can. I did not die when it went to 9.7, nor did I die when it went to 1.6, and those are probably not the high point nor low point of my swings.

Hang in there Chuck. I wouldn't worry too much about the temporary low numbers. The Cleveland Clinic released me with an INR of 1.6 Even Lars was not concerned!
And a comment about Quest near me. I never have an appt. and go in and out usually, in 5 minutes. Very quick and efficient.

 

[newarrior]

I agree that going into the surgery in good health, with good diet and regular exercise, probably significantly increases the chance of a good recovery and increases the likelihood of being back up in the saddle soon.

agree

 

[vitdoc]

I was just reading over this forum. I was struck by the sudden increase of the INR over a few days. I suspect you were on amniodarone in the hospital and this was continued on discharge. So I would be surprised that the INR would change that much so suddenly. My first reaction to an unexpected weird lab result is to repeat it. I bet also seeing how low the INR got so fast with the vit K is that your INR was likely never 9. So now you have overshot were you want to be. Also did any of your physicians review all of this? Was it through the Nurse Practitioner? The last thing you want is to have a clot develop on the valve or other surfaces that have yet to be covered by your own cells.

 

[Chuck C]

I was just reading over this forum. I was struck by the sudden increase of the INR over a few days. I suspect you were on amniodarone in the hospital and this was continued on discharge. So I would be surprised that the INR would change that much so suddenly. My first reaction to an unexpected weird lab result is to repeat it. I bet also seeing how low the INR got so fast with the vit K is that your INR was likely never 9. So now you have overshot were you want to be. Also did any of your physicians review all of this? Was it through the Nurse Practitioner? The last thing you want is to have a clot develop on the valve or other surfaces that have yet to be covered by your own cells.

It is not surprising to me that my INR shot so high, in that amiodarone has an amplified effect on warfarin. I was on amiodarone via IV near the end of my hospital stay, but the mg was actually much lower. Upon release, they upped me to 800mg/day amiodarone. The one publication published on the effect of amiodarone on warfarin is that it amplifies it severely. Even though the study only looked at a max of 400mg/day amiodarone- half of my daily dose, the conclusion of the study recommended cutting warfarin by 40% when on 400mg per day amiodarone, with linear relationship if he dose was smaller, such as 200mg/day or 100mg/day.

So, amiodarone at 800mg was likely increasing the potency of warfarin something on the order of doubling my warfarin dose. My guess is that we did not see this effect yet in the hospital, due to the slow action of warfarin. But, by the time I was released on Monday, I had the double dose effect of Sunday kicking in, then three more days of what would effectively have been double warfarin doses. I am not surprised that INR went to 9.7.

I am on 81mg of aspirin daily, per prescription. For today only, I took an extra 81mg to reduce risk of thromboembolism, in case INR is still low.

Monday's INR will be very interesting. If I had to guess, I am going to give it a wide range or 1.4 to 6.0. Even with the somewhat megadose of 4mg of warfarin Saturday and Sunday, I can't see it being over 6.0 and probably not over 4.0. If it is below 2.0 that means that there is still lots of vitamin K in my system- enough to keep INR low. Given the half life of vitamin K, there is still likely a fair amount in my system. Again I'm guessing here, but I believe that there is a greater change that I will be below range on Monday than above range. Of course, being in range would be a very welcome thing to see. Really anything 2.0- 4.5 would be a very welcome thing to see. My target range is 2.5 to 3.5.

 

[Chuck C]

My first reaction to an unexpected weird lab result is to repeat it

Agreed. If I had a home device I would have done so immediately. As it is, however, I am at the mercy of the lab and their hours right now. By the time we found out about the 9.7 INR they were closed for the day, so we had to treat it as if it was the actual INR and also, no way to know if it is still climbing at this point. Thus, the treatment with Vitamin K.

 

[pellicle]

I bet also seeing how low the INR got so fast with the vit K is that your INR was likely never 9

thats a possibility for sure, but given a large dose of Vitamin K that sort of drop within 24 hours is what its supposed to do ... reverse the effects. Especially with 5mg of VitK ".. and have have 2.5mg of k1 and 2.5 of k2 "

from Warfarin reversal

table 2
Table 2
Options for warfarin reversal

Type of reversal​

Approach​

Rapid (complete; within 10–15 minutes)	PCC (immediate replacement of vitamin K dependent coagulation factors) plus IV vitamin K (switch on hepatic synthesis within a few hours)
Fast (partial)	FFP (immediate replacement of vitamin K dependent coagulation factors—but the correction of the coagulopathy is partial)
Prompt (within 4–6 hours)	IV vitamin K
Slow (within 24 hours)	Oral vitamin K
Ultraslow (over days)	Omit warfarin dose (no vitamin K)

FFP, fresh frozen plasma; IV, intravenous; PCC, prothrombin complex concentrate.

ps: @Chuck C Table 4 is worth a look too mate

 

[Chuck C]

Will know INR reading tomorrow morning.

In the past few days, with a high of 9.7 and a vitamin K induced low of 1.6, it will be interesting to see. I have a pretty good feeling that it will be 2.0 to 5.0, which will be fine until it can be fine turned further over the next few days, although I can't know for certain what it really is.

Here is why I have a gut feeling about it. I have a blood glucose monitor, with a lance. I lanced myself and noted that the blood took considerably longer to coagulate compared to before being on warfarin. Yet, it did not take forever and did coagulate. Eager to see what it really is.

In that my last reading was 1.6, and having no way to know if vitamin K still had it on the way down, I took a few steps that may have decreased my risk of thrombosis. With the blessing of an endocrinologist friend of mine, I took at extra 81mg of aspirin today. I also ate a few tomatoes, which have been shown in studies to reduce thrombosis and had a couple of drinks as we celebrated Easter; one drink of alcohol has been shown to reduce the occurrence of thrombosis for 6 hours after consumption. So, maybe those actions may have helped a little, and in any case I did not have an event.

Crossing fingers: Apt at Quest is 9:45am and should have results in 3 hours, with the rush order. Then dose warfarin accordingly. I feel as though I have learned a lot through this and am eager to get my Coaguchek so that I can take more control over my INR. This experience has really reinforced that I am not comfortable leaving the monitoring of my INR to other people.

Setting aside the INR issue, I feel amazing. I continue to feel stronger every day. I am constantly reminding myself that my sternum and valve are still healing and, regardless of how I feel, follow all of the guidelines for taking it easy.