Low INR

[Tinabobina]

I’ve recently had a mechanical valve replacement procedure on February 10th and ever since I’ve been testing below the range for INR levels. Has anyone experienced this? I have been avoiding leafy veggies for the most part because of the fear of it lowering it even more.

 

[Chuck C]

I’ve recently had a mechanical valve replacement procedure on February 10th and ever since I’ve been testing below the range for INR levels. Has anyone experienced this? I have been avoiding leafy veggies for the most part because of the fear of it lowering it even more.

Hi Tina,
You've come to the right place. I will soon be in your situation, as I am getting a mechanical valve in one week and, like you and everyone else with a mechanical valve, will be on warfarin. I can't help you with low INR, as I don't have experience yet, but there are some very experienced members here who can very much help give you guidance in this regard. Are you self testing?

 

[Tinabobina]

Hi Tina,
You've come to the right place. I will soon be in your situation, as I am getting a mechanical valve in one week and, like you and everyone else with a mechanical valve, will be on warfarin. I can't help you with low INR, as I don't have experience yet, but there are some very experienced members here who can very much help give you guidance in this regard. Are you self testing?

I haven’t self tested yet, they are still trying to find my dosage levels and so far I’ve been having an in home nurse come once a week for now. I will be doing that soon once the classes are open for me in my area

 

[pellicle]

and ever since I’ve been testing below the range for INR levels.

so, the answer is simply "increase your dose"

that's it

if you were stable just after surgery and you are now a few months lower INR then that is because you are healing from surgery and you require more. I discussed this recently here. Can't find that post quickly but in the meantime this is the same points:

https://www.valvereplacement.org/threads/inr-has-been-1-77-for-two-weeks.887570/post-898012
what drug are you taking, who is doing testing, how often and where on this lovely planet are you residing?

 

[pellicle]

got it:
https://www.valvereplacement.org/threads/had-avr-performed-2-25-21.887924/post-903372

 

[Superman]

The beauty of warfarin is there is no “right dose” or “too much”. There is simply the dose that gets you in range. For some, that’s 3mg daily. For me, it’s 6mg daily. Some are up in the teens. People metabolize things differently. In my 20’s I was typically around 4mg’s daily, but that was 20 years ago.

Right now, for you, I would speculate the challenge is the changes your body goes through after such a traumatic event. Your metabolism changes daily as you heal. It can take a frustratingly long time to get to a fairly consistent predictable dose because of that healing.

 

[user 16827]

hi Tina, yes it took me a few months to stabilise my inr. ( it's very common )
i was always low , as the others have stated it takes a while post surgery to adjust.
i would eat your usual diet though and dose accordingly or you may start a roller coaster once you reintroduce vitamin k..
good luck.

 

[Unicusp]

got it:
https://www.valvereplacement.org/threads/had-avr-performed-2-25-21.887924/post-903372

Thanks Pellicle. I missed this (the detail) last time you posted. That helps me understand now why I have the opposite issue of the poster above. My INR continues to be on the high side and I continue to lower the dose, now only at 2.5mg/day. I checked my Albumin level last measured a few weeks ago, and it was very low:

So, I guess as that slowly increases I will need to adjust my warfarin dose upward.
I have another INR check tomorrow at the local lab.
I can tell it is still high from my morning nose bleeds (minor).
Thanks!

 

[ATHENS1964]

After the surgery the hematocrit is low this is the reason that the inr has fluctuations, in a short time everything will be fine, I think you should eat vegetables.

 

[dick0236]

.......... I have been avoiding leafy veggies for the most part because of the fear of it lowering it even more.

Hi Tina. You can get a lot of good "no-nonsense" suggestions from this forum. It seems you are only about one month out of surgery and probably on some post-op meds. It may take a while to get your INR to settle down....but, by testing every week your doc should be able to get you in range pretty quickly. I would not alter my normal diet. Modern dosing says "dose the diet.....don't diet the dose".

Don't try to "hit" or "stay" at a particular INR number.....just try to stay within a reasonable range......usually 2.0-3.0 or 2.5-3.5. Once you get your INR settled down it is not difficult to stay in, or close to, your range without making you paranoid over INR.

 

[pellicle]

That helps me understand now why I have the opposite issue

Happy to help

 

[Keithl]

I’ve recently had a mechanical valve replacement procedure on February 10th and ever since I’ve been testing below the range for INR levels. Has anyone experienced this? I have been avoiding leafy veggies for the most part because of the fear of it lowering it even more.

What range are you trying to hit? How recent and what valve in which position?
I was fixated on the numbers at first as it probably took 2-3 months to get fairly consistent INR readings. Are you on warfarin? Are you also on a daily 81mg aspirin?

I find my body takes for more than the normal 3 days to acclimate to any dose change. That said I stop worrying about being out of range if not by much. My range is 2-3 and I have been as low as 1.7 and high as 3.5. I actually fairly consistent on my current dose at a few point I missed checking every week and went 2 weeks. I have an aortic valve and learned that clotting on the aortic mechanical valve is harder than other positions. I was so stressed when I need to go off warifrin for a colonoscopy and then had a bleed I was freaking out about it. Then several docs and then my cardio told me clots on aortic valve are very hard due to the forces of the blood flowing through it. Other valve positions have higher risks.

 

[pellicle]

My INR continues to be on the high side and I continue to lower the dose, now only at 2.5mg/day

be careful of "undershoot" ...

 

[Unicusp]

Yes, I fully agree. The dosage changes are per my doctor. I have another lab test tomorrow morning so it will be interesting. I am very curious where it will be this time. My diet is consistent. Will see.....thx!

 

[pellicle]

Yes, I fully agree. The dosage changes are per my doctor. I have another lab test tomorrow morning so it will be interesting. I am very curious where it will be this time. My diet is consistent. Will see.....thx!

just as a reminder of what sort of high is "problematic"

and so anything "over range" but under 5 is not really a huge risk.

can you remind me when you had surgery?

 

[Tinabobina]

I’ve had surgery February 10th,

Hi Tina. You can get a lot of good "no-nonsense" suggestions from this forum. It seems you are only about one month out of surgery and probably on some post-op meds. It may take a while to get your INR to settle down....but, by testing every week your doc should be able to get you in range pretty quickly. I would not alter my normal diet. Modern dosing says "dose the diet.....don't diet the dose".

Don't try to "hit" or "stay" at a particular INR number.....just try to stay within a reasonable range......usually 2.0-3.0 or 2.5-3.5. Once you get your INR settled down it is not difficult to stay in, or close to, your range without making you paranoid over INR.

The clinic told me my range should be between 2.6-3.5 I believe. I’ve always came in under for some reason. I was told not to take aspirin, or Ibuprofen and only take acetaminophen.

 

[pellicle]

Hi

Aortic valve?

The clinic told me my range should be between 2.6-3.5 I believe.

Normal for mitral valve

I’ve always came in under for some reason.

How far?

I was told not to take aspirin, or Ibuprofen and only take acetaminophen.

Interesting, aspirin is normally recommend ibuprofen is an interesting issue, yes acetaminophen, but care is needed if taking that for days.

 

[Superman]

I’ve had surgery February 10th,

The clinic told me my range should be between 2.6-3.5 I believe. I’ve always came in under for some reason. I was told not to take aspirin, or Ibuprofen and only take acetaminophen.

Aspirin as pain relief is generally avoided in favor of Tylenol. However many of us are on low dose (81mg) aspirin daily along with our warfarin.

Ibuprofen is an anti-inflammatory. I don’t take it for a headache, but if needed, it can be done. Just test your INR and dose your warfarin accordingly to stay in range.

Warfarin takes something like three days to fully metabolize. It’s not like an allergy where we eat the wrong thing and are at risk of bleeding out at the table.

I have a St Jude in the aortic position and generally stay between 2.5 and 3.5 as well.

 

[Unicusp]

just as a reminder of what sort of high is "problematic"

and so anything "over range" but under 5 is not really a huge risk.

can you remind me when you had surgery?

Surgery was February 19th. 4 weeks ago this Friday. Trying to stay 2.5 to 3.0
Will have results this afternoon

 

[RAS]

This is an interesting topic to me. It took 3 months to get to a stable INR after AVR in 2006.
In addition I was diagnosed with fibrin strands on my valve that first year. I did some research back then and found one small study that found formation of strands commonly occurred in the 6 months after surgery and rarely after 6 months. The study concluded that more aggressive anti-coagulation should be considered in the days after surgery.

I'm not sure that would actually work to prevent the fibrin strands, but as I read through this thread and remembered that study, I thought it would be interesting to look back at my dosing and INR stability in the weeks after surgery compared to the two periods where I had to hold warfarin temporarily for a procedure (colonoscopy in both cases).

Results

5/4/2006 - 8/7/2006: Avg. 4.5mg/day: INR took 2 weeks to ramp up to target range, but was not stable until the dose increased after first 3 months.​

8/8/2006 - 1/14/2011: Avg. 6.4mg/day: In early Jan 2011, warfarin held for 3 days in advance of procedure.​

1/17 - 2/7/2011: Dose first 3 weeks after warfarin resumed: Avg. 6.0mg/day. INR took 8 days to get in target range and was stable after 17 days.​

2/8/2011 - 1/25/2021: Avg. 6.3mg/day: In early Jan 2021, warfarin held for 5 days in advance of procedure.​

2/1 - 2/21: Dose first 3 weeks after warfarin resumed: Avg. 6.5mg/day: INR took 17 days to get to target range and has been stable since then. (now at average 6.0mg/day).​

I know there are lot of other variables in play here, but my own small sample size does seem to align with that study I read years ago.