New to Coumadin and vitamin K

[Eva]

So I just had a new mechanical valve put in 10 days ago. I was at 2.2 two days ago and get my next test tomorrow morning. I take 7.5mg a day for now. My diet includes a decent amount of Vitamin K via low sodium cold pressed organic vegetable juice that get some a lot of potassium as well as other nutrients every morning and then for lunch I have an Evolution Fresh Cold pressed Green Devotion which also gets me a bunch of potassium, but has spinach and kale with vitamin K. And lastly I eat salads 3-4 days a week for dinner where we use our own home made dressing with avocado oil (know to impact Coumadin). I and trying to figure out how to phase these items back into my diet without sending my INR on a wild ride. I can’t seem to find any guidance on how much vitamin k it takes to impact INR and then how quickly. Thanks for all your suggestions.

For me, some medication, one beer or any other alcohol (> 4 oz!!) elevates my INR. But with time, I automatically adjust my dose that night. With time you’ll become also familiar with what affects your INR personally!
Food wise, I stay somehow consistent. I always have greens either in salad, smoothies, or in stews.
If you’re into vitamins, check if they have vitamin k. One time I took calcium that contained vitamin k. I didn’t know and was confused for a while about the change in my INR.
Don’t fret about it!

 

[pellicle]

So a good bit of this is personal preference.

true, although another bigger bit is following directions. When I first started warfarin my surgeon gave me a range of INR between 2.2 ~ 3, I follow that direction still. However it has not stopped me from understanding, learning about the why and what are the risks (so that I don't panic) if I find myself outside those bounds.

Knowledge is strength

For me a .5 changes seems significant.

in what way?

When I go from 2.5 to 3 I consider it a move.

which it is, because now you are on the edge of your boundary ... if you were at 2.2 and rose to 2.7 that is also 0.5 change and not something to take action about. It is this sort of vagueness in your post which I was commenting on.

As well as you still have not mentioned what your daily dose is so any reader attempting to learn from your post will be lost. If you take 5mg daily then 1mg is a significant alteration, but if you take 20mg a day it is not. So if you're offeing advice its important to make that in a way that others can transfer that to their situation (because we are all on different doses).

But not always necessary to change the dose.

exactly my thoughts too (thus my point of having a steady hand on the dose tiller)

Depending on what I eat it will impact my INR. Eating 1 spinach salad or 5 during a week will make a difference for me.

its a good observation, but the point that is being made here is that how are you sure? "Old Wives Tales" start with someone saying something with totally no substantiation or backing and then others read it and just start telling people "I read that having a salad disturbs your INR ..." and next thing you know you've got people eating badly and coming here cyring that "I won't be able to eat my wifes salads anymore" like its their last supper (and yes this has been a relatively common thing).

I like to stay between 2-3 INR and I don't really like 4 or 5.

Agreed, and I was not proposing that you should, just providing information to demonstrate that when you find yourself at 4 or 5 that while its happened its not very risky, so there is no need to feel anxiety and you can steer it back without concerns.

What I try to do is get people to know how to steer it back without causing a YoYo effect in their INR which often comes from micro-managing their INR and their dose. The fact is that many times an excursion to 3 will return with no assistance (but that's why we test weekly, to see that it did)

Again my preference. When you cut or fall the higher INR will allow more bleeding issues. Again my preference. Depends how active a person is and what your risk profile might be.

These points are true and I'm not sure why you say its your preference when indeed its actually a fact. You speak about preferences, but are they? Or are they "following directions"?

My preference is for black coffee (unless its a flat white) and my steak medium rare. Thats a preference. I stay within INR 2.2 ~ 3 because 1) I'm following my surgeons directions because I expect he knows what he's on about and 2) because all my reading combined with my knowledge in other areas has shown me why he chose that range.

So I stick with it not because its my preference but because I was directed to (and sought to understand why and agree with that).

Best Wishes

 

[pellicle]

Science nerd.

I was Beaker before I learned stuff to help me not panic when I was out of range. It went from just blindly doing "what the doctor said" to understanding and understanding the reality of risks


and fireproof paper ;-)

 

[almost_hectic]

So a good bit of this is personal preference. For me a .5 changes seems significant. When I go from 2.5 to 3 I consider it a move. But not always necessary to change the dose. Depending on what I eat it will impact my INR. Eating 1 spinach salad or 5 during a week will make a difference for me. I like to stay between 2-3 INR and I don't really like 4 or 5. Again my preference. When you cut or fall the higher INR will allow more bleeding issues. Again my preference. Depends how active a person is and what your risk profile might be.

I'd have to agree that .5 is significant, especially if its to the lower. Especially since my original range was set at 1.5 to 2.0. Everything is personal preference at some point. Do you choose to listen to your doctors, do you choose to ignore the medical community and go it alone. Thats a choice you can make. I know for me if I went that route my cardiologist would probably not keep me on as a patient. My insurance probably wouldn't cover for prescriptions if they aren't a regular dosage. Have I self adjusted, yes I have. Do I make it a regular practice, no I don't. I try to maintain a regular INR but it still fluctuates, so I stay mindful of what I eat, how much and when. Its not too hard. Usually it works out, sometimes I veer out of range. My INR self reporting alerts my cardiologists office, they call to see whats different or why, we discuss. They may suggest a change but usually don't.

 

[Keithl]

I am still dialing in my INR, left hospital at 2.2, but 3 days later when home and went to local clinic it was 3.5. I am frustrated as the clinics here in Atlanta seem to be lazy and only use the Couga-check XS Plus. I left my Coumadin at 7.5mg and ramped back up my Vit. K and now 3 days later INR is 2.5. I assume this is where 7.5 will keep me, but I expect subtle changes as I eat salad 3-4 times a week during the week so I expect it to bottom on Thursday/Friday and then peak Monday after 2 days of no salad. The good thing is the salad is only a small portion of my Vit. K as I drink a lot of organic vegetable juices that give me decent dose of Vit. K each day. Very annoying that no one does a blood draw until your INR is way out of range, I was quote 8+ for blood draw. This is exactly why I would not let these people in Atlanta operate on me, lazy short cut processes.

 

[pellicle]

Hi

.... Everything is personal preference at some point. Do you choose to listen to your doctors, do you choose to ignore the medical community and go it alone.

well of course I assume you mean "for being dosed" ... not for their information and research literature which is available, from which you can learn.

I know for me if I went that route my cardiologist would probably not keep me on as a patient. My insurance probably wouldn't cover for prescriptions if they aren't a regular dosage.

In Australia (and parts of Europe that I know about) that's exactly what most people do. The price of Marevan brand warfarin is AU$17 for a bottle of 50 5mg tablets (and in Finland it was € 12 for a bottle of 100 5mg tablets ... I don't know what the costs of the same.

I'm sure you will still find a cardiologist who will treat you for your heart condition, but not of course 100% certain.

.... I try to maintain a regular INR but it still fluctuates

This is perfectly normal, and its more the exception than the rule that it does not. Were it the rule (that it didn't fluctuate) then weekly monitoring would simply not be needed. I believe that the issue is that most people have insufficient evidence because almost no one bothers to post their data and the occasional person posts "mine is dead stable" (with no supporting data).

Here are some of my records:

Note that my Dose scale is not the classical 0 ~ 10 (or whatever) but is a narrow selection in one case 5 ~ 10 for the purposes of making more obvious my minor dose changes graphically (amplifying them so to speak).

And this one from an older poster from another forum

I have discussed my own (and this) INR chart with my Cardiologist and my Surgeon (took them in on my tablet) and both remarked that these are what he calls stable INRs and observed that my handling of variances in INR was well done (and better than any clinic they'd seen).

So some variation is totally expected, indeed if it were not then we wouldn't even be having discussions about it.

I would expect that if you did a thorough and rigorous testing and documentation you may find that over a 3 year period (I personally have over 6 years of every test done both weekly testing data and Ad Hoc tests where I may test daily or bi-weekly) and I have yet to meet many people who have such a collection (I've met two or three).

Best Wishes

 

[tom in MO]

...I am frustrated as the clinics here in Atlanta seem to be lazy and only use the Couga-check XS Plus.... Very annoying that no one does a blood draw until your INR is way out of range, I was quote 8+ for blood draw. This is exactly why I would not let these people in Atlanta operate on me, lazy short cut processes.

They are not lazy or taking short cuts. They use the meter because it provides medically equivalent results and is accepted and approved but at a significantly cheaper price and shorter time frame.

Some would say that using a meter for someone just out of the hospital with an AVR is better care than using blood draws.

With real time results from the meter they can send you home with an adjusted dose which is critical for a patient newly on warfarin from an AVR. They do not have to depend upon someone getting your results, reading them, getting a new dose from the nurse or doctor in charge and then reaching you by phone. This is all done the next day. Using a meter and getting real time results, getting a new dose and getting personalized help all at the same time is better and cheaper patient care than a blood draw with results later on.

Just because they take a blood draw doesn't mean they don't use a meter in the lab.

They do blood draws for high levels since the meters are only approved for a specific range. I think they do blood draws for unexpectedly out of range values to make sure that your INR is not being skewed by one of a small number of things.

 

[Keithl]

I just know these meters are not likely calibrated or well maintained and it would be nice to go up against a lab draw periodically to check for accuracy.

 

[pellicle]

I just know these meters are not likely calibrated or well maintained and it would be nice to go up against a lab draw periodically to check for accuracy.

These meters are well calibrated and give results that are well within the needs of therapy guidance.

Years of testing has shown that within a certain range they are quite sufficiently accurate.

I believe you are just being cranky

 

[Keithl]

Not cranky, anal I like accuracy. I will take what they give me, but will error on the higher side of the range since the stats show more issues occur with lower INR than higher INR.

 

[pellicle]

Hi

Not cranky, anal I like accuracy. I will take what they give me, but will error on the higher side of the range since the stats show more issues occur with lower INR than higher INR.

noted (although I will remind you that being cranky and moody and slightly illogical (not apparent to you usually at the time) is actually normal)

So let me address a few points

As a background, the calibration of the system (strip is the system, the device is little more than a CD player with the CD being the important part) is done by batch and is what is encoded in that small chip that comes with each batch. The operator is requested to confirm this at the beginning of the test.

Now, as to accuracy, these graphs are sourced from a study done on the XS system. I would be happy to try to organise getting that study to you if you wish to read it for yourself (if for instance you you may think I'm biased, or you are simply keen to read)

I think they show well that the discrepancy from the agreement from a well calibrated lab result (and be aware that there are many ISI standard reagents that they may wish calibrate against, all of which also have different response curves. So its important to remember you are not dealing with measuring steel with a micrometer here but you are measuring something more nebulous.

With respect to your point about not being cranky and being anal, I'm a software developer of some decades experience. I have worked with major financial institutions developing key (tax) reporting systems and I assure you I know Anal and live it. But your reply seems more like you're cranky to me (of course I don't know you and ASCII tends to mask and distort intention and emotions in the ability of the writer (who may simply be being terse fighting with a phone keyboard) and the reader (who may have phrased the same thing differently).

As I have offered before, if you wish to contact me I'm sure I can provide more support (for at least your informational needs) and assistance in research paths.

Now, as I mentioned before, the introduction of warfarin is a delicate matter with possible (not likely, but hey, neither is surgical infection and I've had that) dire consequences. So they are likely to be taking it prudently.

Your dose is on the high side for introduction to warfarin therapy and so I'm assuming that this has thrown them off their "normal story" and they are unsure how to respond (which btw is simply to keep increasing dose until the "intention to treat" INR is reached. However they are not specialists they are usually generalists (and there are very few specialists in INR management).

I'm not sure if I've mentioned it before (I recall Warrick saying something and me supporting that, but that may have been someone else) that your INR will not remain stable on that dose (of 7.5) for long and will continue to rise. I think I earlier predicted you will probably settle later on a higher does (so I'll fish out somewhere over 10 right now as a gut feeling).

Warfarin is not like other drugs, it is not dosed by body mass but by your specific P450 response (also influenced by which brand you were started on because different "formula" have different enantiomers of warfarin (see stereo chemistry and think of your hands) which have different half lives

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1401216/

If I may give a metaphor which is not strictly accurate: Breathing is something we do, but is not something which is "Steady State" depending on what is happening to your metabolism you may breath deeper and faster then other times ... all is designed to keep a very accurate specific level of oxygenation to the blood. Further not all people will respond in the same ways and require different respiration rates to the same "metabolic circumstances"

An introduction to the P450 is possibly well done here:
https://www.ncbi.nlm.nih.gov/books/NBK84174/

If there is laziness in anything its the lack of ever doing these blood tests to understand genotype (which by the way is still being researched in terms of genetic backgrounds of who has them, not their actions) however patient (if one reflects on the other meaning of the word) testing will yeild the best answer anyway, albeit in slightly longer time.

Best Wishes

 

[pellicle]

Hi

.... I assume this is where 7.5 will keep me, but I expect subtle changes as I eat salad 3-4 times a week during the week so I expect it to bottom on Thursday/Friday and then peak Monday after 2 days of no salad. The good thing is the salad is only a small portion of my Vit. K as I drink a lot of organic vegetable juices that give me decent dose of Vit. K each day.

I will be interested in this if you report it. The fact of the matter is that Vit K has a very rapid re-initialization of coagulation (thus it is administered in ER to rapidly restore coagulation in accident situations), while the pathway that warfarin uses to create a lower coagulation rate takes time to establish (because it is indirect). Vitamin K is like throwing fuel onto a fire and Warfarin is like slowly starving it of fuel. (another metaphor which is not perfect). After the administration of Vit K the residual levels of warfarin in your system will see your INR return to where it was sooner than you may expect (thus confusing many who say my salad ate my results).

But if you look at the doses of Vit K needed to effect a change in INR they are WELL outside the scope of food. I refer you to this experiement I helped Gym Guy construct and execute (although I only advised and 2nd opinioned as he was well across this himself). I am sure I posted it but can't find it again, so here is a paste from my previous notes:

Day 1. No Coumadin.
11am 2.6 INR
12pm 400g of raw blended spinach
4pm 2.3 INR
4:30pm 150g or raw blended spinach
10pm - INR 2.3 (measured twice) no change.
10pm - another 400g of fresh blended spinach
Off to sleep - Note: in 24 hours consumed - 1000g of fresh spinach

Day 2. No Coumadin.
8am 1.8 INR
9pm 1.4 INR

Day 3. No Coumadin. 9am 1.2 INR.
12pm Epidural. Should be 1.1 by then.

Consider the amounts consumed here (I encourage you to weigh out some spinach and see what these amounts look like). The problem is that for so many numbers, units (milligram vs microgram) proportions and maths are just not "how they think", and so are confused by what they read.

 

[Keithl]

I introduced about 150-200mcg of Vitamin K back into my diet daily and my INR went from 3.5 to 2.3. I have been on 7.5 for about 10 days now. Sure there is still some fluctuations likely going on and I am testing twice a week and hoping to get approved for home testing quickly as running to the clinic is killing a lot of time since they only use the meter anyway. I still need to reintroduce a few supplements like CoQ10, garlic, fish oil and Magnesium which should not have any major impact all the Vit. k I was going to reintroduce has been brought back into my diet now so now it is wait and see where things settle down to.

I get most of my Vit. K from organic cold pressed juices so that is why the swing as these have high Vit. k in them, but also high potassium and other vitamins and minerals. The good thing is drink these every day 6-7 days a week.

 

[marvsehn]

So I am not going to say much more. However, I do believe that medical treatment is personal preference. That said, I have been testing weekly since 2012 and below is my chart for the last 2 years by week. Actual weekly dose rates and INR. I have only been outside of my 2-3 a few times, couple high and a couple low. I evaluate where I go (travel) what I do (physical exercise) and what I eat.

Thanks for all your comments. I got me to take another close look at what I am doing and the result. Weekly dose scale on the left, INR scale on the right.

 

[Savymom]

I could be wrong, but I wonder if it would be better to just start taking your supplements now, instead of waiting and having them potentially affect your INR again later. I do remember it taking some time for mine to settle into its spot, and going to the clinic seemed very annoying in the beginning. It also took a long time for it to “settle” down. As your activity increases, your INR will also fluctuate. 10 days post op I was barely walking. 20 days post op I could walk a couple blocks. 3 months post op I was lifting weights and could jog a mile or two. You get the idea. I now take 10mg daily, and 12.5 min, wed, and Fri.

I thought for sure I’d do home testing. In fact I might still do it, however.. now that I’ve stayed in the same range and 10 months out, I’m visiting every 8 weeks, which isn’t so bad.. the apt is less than 10 minutes. I meet with the same nurse every time. Although home testing might be nice, I’m ok with the apt every 8 weeks at this point in my life.

Good luck!

 

[pellicle]

Thanks for all your comments. I got me to take another close look at what I am doing and the result.

excellent, which is exactly why in academic circles we are required to defend our propositions ... not because anyone likes attacking, but because the defender gets to consider their assumptions and stuff.

I'm glad something useful has come out of it for you.

 

[tom in MO]

My cardiologist wants me to check with them before I make any changes in drugs or supplements, so beware of how you change your diet. For example, they had me on fish oil before my AVR and told me stop and it was not needed after my AVR and it can affect your INR. The best thing is a varied diet in moderation.

There is no need to "calibrate" the meter itself on a regular basis since all of the calibration required is on the strip. All the Quality Control required is on the strip and in the firmware. The quality system and regulations that assures your INR is therapeutically relevant are called Good Manufacturing Practices for Medical Devices. In the US, I believe it is 21CFR820, it covers your valve and the meter.

 

[Keithl]

Well today is 6 weeks and it looks like my INR is settling down in the 2.5-2.7 range and I am on 6.25 dose per day. Let’s see if it stays there. I have a new cardiologist who is very collaborative. I told her my desire is to stay 2.5 forever vs. the 1.5-2.0 recommended by surgeon due to me having and On-X. She was fine and said after 90 days we will adjust to 2.0-2.5. Unfortunately they do not write prescriptions for INR meter and just order a service. So it looks like e-bay it will be since the CoaguSense PT2 seems to only b sold via Wilburn Medical and he requires a prescription. So looks like CoaguCheck via e-bay will be my path.

 

[pellicle]

Well today is 6 weeks and it looks like my INR is settling down in the 2.5-2.7 range and I am on 6.25 dose per day.

don't be surprised if that moves up in a few months to a higher dose ...

 

[Keithl]

don't be surprised if that moves up in a few months to a higher dose ...

I will not be. Funny how they want me testing every 2 weeks and I said weekly for now. As soon as I get an INR meter sorted out I will do home testing once or twice a week for a while until I am sure it stays consistent for some period of time. I also still need to ramp back up a few supplements that may impact it. At least this new cardiologist is working with me vs. my old one that was difficult to deal with.