Low INR

[Yvonne]

I posted about this in the post-surgery topic, but it was suggested I post it here, so here I am

I had AVR in January and had a St. Johns valve put in. Now, I'm on a blood thinner, of course. I'm on Warfarin 3mg per day. At first my INR was within the normal range, but in the past 6 weeks or so it's been low. I've had readings of 1.9, 2.1, then back to 1.9. My doctor has adjusted the dosages each time (4.5 mg on alternate days, now I'm on 4.5 mg 5 days a week with 3 mg on the other 2 days). I had a blood test last night, but the results were delayed and I won't know until tomorrow.

The other meds are a 81mg aspirin and Toporol (75 mg). That's all I take and these meds were all prescribed on my discharge from the hospital. I was also taking Amiodarone (100 mg), but that was stopped 3 months after the surgery.

Since my surgery I've had an echo and a holter monitor - both were normal.

I exercise (cardio exercises) 3X a week, which I was doing before the surgery. I have no problems exercising, no shortness of breath, nothing.

As for diet, I'm on weight watchers maintenance. I lost 85 lbs before my surgery and have maintained it ever since. I haven't gone up at all. Although I did lose another 7 lbs after surgery, but that went back to what I was before surgery. No real change.

Honestly, I was never a big vegetable eater in the first place, so it's not like I'm eating too much now that is causing the INR to go down. I eat very little vegetables

So, how do I get the INR to go up? My dosages have already been adjusted. Of course this might be a moot point when I get my blood results tomorrow. Maybe I'll have good news and I'll be within range again.

 

[dick0236]

What is your range? 2-3 or 2.5-3.5 or other? The protocol I use (Al Lodwick) suggests an increase of 10-15% per week for a 2-3 range and 15-20% for a 2.5-3.5 range if you are currently under 2. Recheck in one week.

I don't try to stay exactly with the indicated percentage increase, or decrease. I round the numbers to make them fit the dosage I keep on hand.

Personally, I try to keep mine towards the high side of my range (2.5-3.5). An INR that is a little high doesn't bother me but an INR at 2 or below gets my attention quickly.

 

[Yvonne]

My range is supposed to be 2.5-3.5. The readings I've been getting lately are 1.9, 2.1 and then down to 1.9 again. So, that's low.

 

[dick0236]

My range is supposed to be 2.5-3.5. The readings I've been getting lately are 1.9, 2.1 and then down to 1.9 again. So, that's low.

Yep, those INRs are low. If the test you just took is still around 2, and since I imagine you have only 3mg tabs, I would try going to 7 days @ 4.5. That would be a 10+% increase and recheck in one week.

 

[Yvonne]

Thanks for the info. That would make sense. If it's still low with 5 days at 4.5, then 7 would be the way to go.

 

[ALCapshaw2]

It's not uncommon for INR to drop as you become more active following surgery.

As your activity increases, your metabolism tends to inrease which will lower your INR.

Increasing your dose (gradually) is the way to go as others have pointed out.

 

[Philip B]

Adjustment

Adjustment

If you're low, the fix is easy. Simply increase your dosage. I typically use 2.5 mg to adjust up or down.

Like others, I prefer to stay on the high side. The key for me is to closely watch for upward or downward trends and make adjustments.

-Philip

 

[Yvonne]

The doctor has been increasing my dosage each time I had the low INR. I went from 3 mg a day up to 4.5 five times a week and 3.5 two times a week. I guess depending on what the new reading is, he might go 4.5 every day.

Does this matter - my other prescription was from one pharmacy and the label said Warfarin Sodium. I took my last prescription somewhere else and it just says Warfarin (same 3mg doses at both places and the same prescription from the same doctor at both places).

 

[Maryka]

Don't do the silly thing I did. Post AVR surgery I went back to taking a multiple vitamin (generic) I had previously taken. I just could not seem to get in the right range. Then I realized that my multi-vite had lots of vitamin K which was influencing my INR.

 

[AgilityDog]

You said you just stopped taking Amiodarone about 3 months ago. Amiodarone really increases your INR.
The Amiodarone is now leaving your system, and the last 6 weeks that has really shown up. It takes 2-3 months after you stop taking it for it to completely go away. It makes perfect sense to me that NOW you're having to adjust your warfarin dosage up to compensate for what the Amiodarone did.
That, combined with more activity, is causing the decrease in INR.

So now it's a case of adjust, adjust, adjust until you find your sweet spot.

You've gotten good advice here on what changes to make. I'm just offering a potential cause to help you not be distressed about it.

 

[Ross]

It takes 2-3 months after you stop taking it for it to completely go away.

Just a little correction, it takes 6 months for Amiodarone to completely leave the system.

Yvonne eat as you always have eaten. Don't change a thing. If you don't like Veggies, that's fine, but don't skip out on any of them because of Coumadin. Everything can be adjusted for.

 

[Yvonne]

Good news! My latest results are in and I'm within normal range again. I'm up to 2.6! The doctor said to stay on the current dosage and come back in two weeks for another test. I'm very relieved.

Maryka - I stopped taking my multiple vitamin before my surgery and never went back to it. After reading your message, I'm glad I didn't.

AgilityDog - Thanks for the info about the Amiodarone. I didn't know that. The PCP knew that the cardiologist took me off it (I wouldn't have been on it forever anyway), so I'm surprised he didn't connect that. Maybe he just forgot about it. Now that you told me that, it does seem like the time frame fits since I haven't changed anything I'm eating.

Ross - Thanks for the info. I was worried that maybe I wasn't eating enough veggies, but then again, I wasn't eating much when I had the higher INR anyway.

Everyone - thanks so much for your support! It really helped talking to people that are experiencing the same thing or have already gone through this. At least I can now relax this weekend and not worry about a low INR. Yay!

 

[Ross]

If you continue to have problems, post everything about dosing, testing, diet, other meds and physcial activity and we'll help you out. More often then not, it's poor management and not the person.


There is nothing wrong with taking a multivitamin with Vit K in it, just make sure to keep getting the same brand or at the very least, the same amount of Vit K in it. Again, everything can be adjusted for.

 

[Yvonne]

Thanks, Ross! The scary part was that the doc kept increasing the Warfarin and yet my INR was going lower. I was becoming sure that something was wrong. Now, I'm convinced (and I could be wrong) that it was coming off the Amiodorane. Also, and I don't know if this matters, about a month ago my BP was low so the doctor reduced my Toporol from 100 mg to 75 mg. I don't know if that had anything to do with it either.

 

[Ross]

I'm fairly sure it's coming off the Amio. Like I said, if you continue to have problems, let us know what's going on and we'll figure it out.