Low INR

[marc_kowal]

So apparently the combination of being on Levaquin and drinking a lot of water has caused my INR to drop a lot. On Wednesday my INR was 3.2 and then it was 2.1, 1.9 and today it was 2.0. My cardiologist initially was trying to get me at the low end of my range of 2.5 to help deal with some blood in urine. But now we're trying to get it in range. My doses have been weds 3.5 mg then it was raised to 4.5mg and then raised to 6 mg last night and to take 6 mgs tonight and Sunday.
Should I perhaps take a half dose (1.5 mg) now to help give me a boost towards getting back in range or am I jumping the gun. I don't like being low but my cardiologist keeps trying to assure me that being low for a few days is ok. It's really starting to get me worried.

 

[pellicle]

Hi Marc

Reading your post makes me wonder if the INR changes have anything to do with Levaquin and water or something to do with an implied reduction of warfarin - as you wrote that your cardiologist was trying to get you to the low end of the range.

I don't understand what yotu have said about your dose, is your normal daily dose 3.5mg to have you in range? Is your normal dose usually steady or alternating?

Is the dose of 6 tonight and Sunday a new level or is it just a one timer to hit your INR back up to above 2?

I would think that a single punch like that would work to deplete vitamin K and raise your INR, but I would myself wish no more than 2 such doses?

Being low as I understand it for a few days is not a big deal with respect to clots and stroke risk. To my understanding they take a little longer to form (although the foundations could be laid) and a return to normal (for us) INR within a few days will do no harm.

To me its a bit of a grey area andI understand your caution. My own inr has visited the 1.7 range on occasion (in hospital with no heparin cover) because they wished to take advantage of clotting (post debridement surgery).

So being low for a little while is probably likely to achieve the goal that the doctor wanted (kidney bleeding right?) and that it went a little lower on your measurement scale should do little harm. These guys (should) do do risk calculations in setting their goals ...

I know for myself that dropping my INR is best done with a small reduction of warfarin and a plate of "Horenso" from my local sushi kitchen.


Let us know how it goes and what you did

 

[marc_kowal]

Sorry, my initial post was a little scatterbrained....being sick and worrying about my INR were a nasty little 1, 2 punch (not to mention my two little boys driving my nuts ) :Face-Raspberry:

My usually dose is M-W-F @ 4.5 mg and the rest of the week is A 6 mgs. This seems to have kept me in range for a long time with minor tweeking here or there. My cardio. originally was going to adjust my schedule to Weds @ 3 mgs and 4.5 mgs every day in trying to get me down closer to my low end of a 2.5 INR.

After 1 day of being on the Levaquin and pushing a lot water, my INR went from 3.2 on Weds to a 2.1 on Thursday. My Cardiologist then adjusted me up to 6 mgs for the next couple of days, in trying to get me back in range. Friday it dipped down to an INR of 1.9 and then today my INR was 2.0.

I decided not to take a half dose earlier today, figured I may be playing with fire. I'm feeling a lot better today, so I'm not drinking as much water today (which may having been flushing my meds from my system too quickly) and I reduced my normal intake of "K" today. Hopefully my INR tomorrow will be a little higher.

 

[pellicle]

Hi Marc

Thanks for the clarifications. Firstly i think its wor saying that the danger of a clot incident is still a low likelihood based on what you have said so far.

As you know I am not in agreement with the methodology of alternating doses over such a range. Many say that it is fine citing poor or no data to back it up. The usual view is that "its OK because the INR takes days to react" - implying some form of buffering. Then that same logic is tossed out the window when they wish to change the state of the INR and check in a couple of days (or the next day) for a result.

Either it reacts relatively quickly or it doesn't

To me I would fully expect to see such variations as you have reported within a few days when mucking around with doses. This is because I would expect the endocrine reactions to be responding (which they do quite fast) to the altered concentration of an unwelcome foreign substance (warfarin) and alter their disposal cycle of that.

So I would look at your target (reducing the INR for a short time to reduce kidney blood levels) and submit that you alreadyhave been on a reduced INR for a short time. If there is still trace levels of blood in the urine i would then ask "how long did y want to keep it low?" To your medical practitioner.

In assume you have been reesting during this time and not straining physically too.

If you want to hover your INR at a steady low level you will neeconsistency of many things , diet , exersize and dose. You can't land an aircraft by rough control inputs uncles a slam into the deck is acceptable.

To my knowledge few people have taken daily INR data for extended periods and published. Ola here was one such. My own monthly reading has shown similar variations in INR to his. Our data supports the view that alternating doses produced cycles in INR related to the alternations. My own findings are that consistent daily doses still result in irregular INR but the variation is less and irregular.

So if y want to make fine adjustments to lower your INR then I suggest
* very regular doses
* measure every day or two days
* do not alter dose daily in responce to change (only after a two or three day trend)
* make such alterations in the order of 0.5mg

Or just take your 3.5 dose for two days then go back onto a daily dose of say 5 and see where that leads for a week. Consider adjustment based on observation of INR.

http://www.valvereplacement.org/forums/forum/home-anticoagulation-monitoring/43179-novembinr
http://www.valvereplacement.org/for...stroke-or-bleeding-event-when-inr-is-in-range


Best wishes