Never ending INR issues- warning LONG post

[tom in MO]

so why don't you lay on us the "proper information" and "good advice" instead of just slinging negative comments from the balcony?

Perhaps even clear up some of those "poor advices" and "misinformations"

Calling me a fool...You're a class act. I know I'm a fool, my dog routinely reminds me

 

[pellicle]

Calling me a fool...You're a class act. I know I'm a fool, my dog routinely reminds me

You have an active imagination. If you don't know or understand the Muppet show I'm sorry. Those guys are famous not for what you imagine I've said. Indeed calling me a class act is just hiding behind semantics when you are insinuating quite negative things. At least I'm up front.

But no information to clear up all the misinformation you accuse all of us who commented of?

 

[Protimenow]

Tom: I didn't see that image as a personal insult. Pellicle pulls from a great number of excellent images. If he posted a picture of two fish talking, would you think he was calling you a fish?

I agree with Pellicle -- you mention a great deal of misinformation.

I'd also like to see what you think was wrong -- and the correction.

 

[pellicle]

in furtherance to my other post in your other thread I submit this (well known pharmacokinetic) information (it is as you say an old source because it was "done and dusted" decades ago):

From MIMS (we have a subscription here at the Uni)

The clearance of R-warfarin is generally half that of S-warfarin, thus as the volumes of distribution are similar, the half-life of R-warfarin is longer than that of S-warfarin. The half-life of R-warfarin ranges from 37 to 89 hours, while that of S-warfarin ranges from 21 to 43 hours.
...
However, there may be a slight decrease in the clearance of R-warfarin in the elderly compared to the young. Older patients (60 years or older) appear to exhibit greater than expected prothrombin time/ international normalised ratio (PT/INR) response to the anticoagulant effects of warfarin.

if you are unfamiliar with MIMS: https://en.wikipedia.org/wiki/Monthly_Index_of_Medical_Specialities
The Monthly Index of Medical Specialities or MIMS is a pharmaceutical prescribing reference guide published in the United Kingdom since 1959 by Haymarket Media Group. The guide contains information about branded and generic drugs in the UK formulary.

 

[pellicle]

Tom: I didn't see that image as a personal insult.

to be honest I'm pretty sure he doesn't either ... its just consistent with his approach of being "prickly" but only to me. I've already shown over years that I consistently say what I think and don't hide it.

 

[Warrick]

https://www.urbandictionary.com/define.php?term=class act&amp=true&defid=1559850class act
A person who is a class act has it together, they have a lot of class in public situations. It can also be used as a diss because you can sarcastically use it to describe someone as podunk.. redneck.. immature.. or downright stupid as hell..
"Those b*tches are a real class act because they dont have a life and start stupid sh*t”. Man i wish i was them.. they are so tight, not"

"That ho must be a cut above the rest of us because she thinks that shes hott sh*t”

Im not quite sure who talks like this...

 

[pellicle]

podunk.. redneck.. immature.. or downright stupid as hell..
"Those b*tches are a real class act because they dont have a life and start stupid sh*t”. Man i wish i was them.. they are so tight, not"

"That ho must be a cut above the rest of us because she thinks that shes hott sh*t”

Im not quite sure who talks like this...

word

 

[Warrick]

Tight

 

[pellicle]

Tight

well apparently "loose" has its benefits too

 

[Superman]

Amazing how much poor advice and misinformation is in this one thread.

Sassyspy, swings that wild, do need professional treatment.

Odd response considering all the professional treatment the OP indicated they had pursued prior to coming back here since the pros weren’t helping.

Anyway, one dietary item oft overlooked is juice intake. For me, cranberry juice sends my INR through the roof. Had a problem years back with blood in my urine. Found out my INR was close to 10.

I had been drinking a lot of cranberry juice at that time. I’ve cut that out of my diet and haven’t had a problem since. I’ve heard, but not experienced, the same with grapefruit juice.

 

[tom in MO]

Odd response considering all the professional treatment the OP indicated they had pursued prior to coming back here since the pros weren’t helping.

Anyway, one dietary item oft overlooked is juice intake. For me, cranberry juice sends my INR through the roof. Had a problem years back with blood in my urine. Found out my INR was close to 10.

I had been drinking a lot of cranberry juice at that time. I’ve cut that out of my diet and haven’t had a problem since. I’ve heard, but not experienced, the same with grapefruit juice.

The way I read her post is she goes into the ER and gets short-term treatment for her high INR. Upon discharge, since her profile shows her being unemployed, I assume that she wasn't getting the routine care for her INR that she needs, thus it once again goes whacko. Back to the ER, where they treat the symptom, high INR, but not the cause. Whether her problem is vitamin K, her meter, or her brand of warfarin cannot be divined by us, she needs better care than the ER. She needs a good cardiologist to partner with her to understand what's happening. You don't get that in the ER. This is a common problem with people that have chronic conditions (e.g. kidney problems, diabetes, etc.) but use the ER or Urgent Care exclusively. Having a mechanical heart valve creates a chronic condition that should receive routine care and not just serviced in the ER when things go out of control.

She never came back, we should all say a little prayer of hope that it's not due to a calamity.

 

[Protimenow]

Cranberry is known to raise INR. Grapefruit juice may interfere with many medications - I, personally, keep far away from it.

There are resources that show the effect that food items have on INR.

Having your own meter, and testing weekly, can help us to catch these swings before they become problems.

Tom: I agree that the E.R. and Urgent Care aren't the best places for people with prosthetic valves to get any type of services. They may take your INR, have someone who knows little about anticoagulation management advise the patient (or just give a shot of Vitamin K if the INR is too high, or give sketchy advice to 'increase your dose for the next day' or something like that if the INR is too low, and send the patient on his or her way.

This may help short-term (long enough to discharge the patient), but does little to address the underlying issues. Unfortunately, in the healthcare system in the United States, unless you've got good insurance, or can afford deductibles (if your insurance isn't that good), or can't afford to visit a cardio, there aren't many options.

In a country where you have to choose between food or housing expenses, or seeing the doctor, all too often the first two are the ONLY choices.

Personally, for me at this time, there is no choice.

(Carefully stepping off my soapbox, so I don't bang anything and get a really large, ugly bruise)

 

[vitdoc]

I will add my two cents to this discussion. First unless the 1.5 mg dose of warfarin was markedly off say really 5 or more mg it would appear to be very unlikely that the generic version of Coumadin was the culprit. Maybe there would be some variation in the bio availability but unless this was some very weird drug obtained in a very odd way it would be hard to believe it caused this much change in the INR. The meter could be the culprit but again these marked swings still would be hard to expect that much meter/strip error. One thing that can be associated with such low warfarin needs would be liver disease. The liver is where warfarin has it's effect and where the coagulation proteins are made. In patient's with cirrhosis of the liver they frequently have elevated INR without any anticoagulation.
So this individual needs a medical evaluation (blood test) for liver function and probably switch to a different brand of warfarin and also check her meter.
When these are done I would likely expect an explanation for this odd behavior. If this doesn't lead to an explanation than a good hematological evaluation of her coagulation system would be called for. Finally sometimes we see weird things and they turn out to be self induced.

 

[Freddie]

Vitdoc: FWIW: I used recalled strips and the results had a BIG swing. Meter results were 4.5 (lab 3.2), 5.0 (lab 3.4) and 4.8 (lab 3.0) to name a few.

 

[Protimenow]

Freddie -- that's why they were recalled. Roche didn't get the word out to disributors or users of the strips (I assume this is because they didn't want a negative impact on their reputation) so, unfortunately, some people were led into unnecessary worry and, perhaps worse, messing with their dosing when they really didn't have to.

With all the users of the CoaguSense XS strips, the recall should have been more prominently publicised.

 

[LondonAndy]

Freddie -- that's why they were recalled. Roche didn't get the word out to disributors or users of the strips (I assume this is because they didn't want a negative impact on their reputation)

I don't know if that is what happened in the US, but here pharmacies were told, and I received a letter from Roche at home, though because I ordered my meter directly from them perhaps.

There have also been a number of posts on here about the recall, including lists of batch numbers affected.

 

[Protimenow]

Unfortunately, strips also are sold on the 'gray' market -- eBay is a big market for the sale of strips. Unless the seller is a medical supply company or other entity that buys from Roche, it may be difficult to get updates the the end-user.

A month or two ago, I bought two strips (for $5, including shipping) just to refresh myself on the operation of the meter. I immediately wasted one strip, and the other strip reported a ridiculously high value. I checked the lot number and saw that this was one of the strips in a recall. I contacted the seller of the cheap strips, told him that they were part of a recalled lot. He had no idea - these were left over from a dead relative's estate.

My point is -- sometimes sellers don't know that a recall was in effect. Sometimes they don't want to go to the trouble of notifying their buyers (especially if they were unable to replace the bad lot).

Roche COULD HAVE issues a press release and made sure that the media published the fact that there were some recalled lots. THIS WAY, those who got the strips from other than authorized dealers could have known about the recall. But, of course, it may have reflected badly on Roche to put out dangerous products.

(One other thing - not entirely on this exact topic - and I've said it before: if you get a result - from a lab or a meter - confirm it before reacting to it. Not all labs are right. Meters can give wrong results if the strips are recalled, or if the test isn't done correctly. Repeating a test, or having it done by a different meter or lab, is probably the best way to validate a questionable result.)

 

[Freddie]

PTN:
My response was to Vitdoc as he mentioned: "The meter could be the culprit but again these marked swings still would be hard to expect that much meter/strip error".
FYI there was no recall in Canada.

 

[Protimenow]

Freddie: Perhaps the recalled strips weren't sold into the Canadian market.

 

[vitdoc]

Freddie, I didn’t say that test stip problems couldn’t cause inaccurate readings. Say going from a 3.5 to a 5. But she went up to over 7 And down again. So yes bad strips could be the cause but given the huge fluctuations less likely. Clearly she needs to be tested properly.