New to Warfarin

[goffrey]

Good morning,
I underwent my 7th OHS on January 19th and afterwards have been put on Warfarin to prevent a clot from forming in my new porcine pulmonary valve. I have never had to be on Warfarin before and it is proving to be a bit of a challenge since my INR levels are very erratic. They range from 1.4 to 6 each week. I am on a life long course of Fluconazole due to a previous bought of fungal endocarditis and these 2 drugs don't "play nice".

My surgery performed at Mayo Clinic and they have been trying manage my dosing and INR levels via the patient portal. One of the issues I am having is the lab where I go back home in Des Moines are extremely slow about getting results and I have not found a competent doctor here to use. I have to go get labs done twice a week currently since my INR keeps bouncing around. I am eating a regular diet. I know the deal with the vitamin K rich foods and my diet is very regular.

Has anyone been on both Fluconazole and Warfarin at the same time? Did you have issues with your INR levels and if so how did you manage it?

 

[vitdoc]

I doubt most people have been on long term fluconazole and warfarin so personal experience may be hard to find. But there is one thing you can do to help yourself significantly. Get yourself a home monitoring device for measuring your INR. These are accurate and the results are immediate. I would be sort of surprised that if you take a constant dose of fluconazole that it would cause such wide swings in your INR. On this site there are many discussions of issues related to home monitoring. I am a bit surprised that your physicians have not suggested that to you. Also in most cases warfarin for non mechanical valves is used temporarily and not permanently. You may have a special reason to stay on it but typically it is used for around three months after surgery with non mechanical valves so your issue may be temporary. Again ask your physicians how long you need to be on warfarin and if home monitoring might be useful for you. Good luck.

 

[goffrey]

My doctor did suggest I get a home monitor and warned me since I would only be on it for 3-6 months they have had little to no luck getting insurance to cover it. I have just purchased one on EBAY and am awaiting it's arrival.

The reason for the swings is due to the fact I was put on IV Caspofungin for 2 weeks after surgery since most of what had grown vegetation during the bout I had with fungal endocarditis could be removed there was part of the conduit that had adhered to part of the heart that could not be removed. So INR dosing was getting there after surgery but just as we were about to get a grip on a good dose we started the Fluconazole and it has been a mess.

My doctors and nurses have been great actually. The internist I had here tried to regulate my INR and was trying to dose me to high so Mayo stepped in.

 

[pellicle]

Hey Goffrey

My doctor did suggest I get a home monitor and warned me since I would only be on it for 3-6 months they have had little to no luck getting insurance to cover it. I have just purchased one on EBAY and am awaiting it's arrival.

that's a great pro-active move.

I suspect its going to be a rocky road for those months, so feel free to reach out if you want a hand managing that. I've been able to tame most INR dragons so far.

The Lancet

Warfarin's primary metabolic pathway involves the cytochrome P450 2C9 isoform, and fluconazole is a strong inhibitor of this enzyme. Avoidance of fluconazole in patients on warfarin is advisable—unless the dose of warfarin is empirically reduced and the INR is closely monitored. ​

if none of that makes any sense then reach out and we can work on this together (and I always encourage letting your medical professionals know you're working with someone and showing them the results).

I know the deal with the vitamin K rich foods and my diet is very regular.

I would wonder, because so far when most people say this its either wrong or exaggerated. Not saying you don't just sayin "I would wonder"
Best Wishes

 

[Warrick]

Perhaps there is an alternative to Fluconazole you can take for the short time you are on warfarin?
I googled alternatives to Fluconazole and Caspofungin is listed as an alternative treatment that doesn't appear to affect warfarin treatment.
Warfarin treatment and antifungal agent caspofungin for severe fungal infection in a patient previously treated with radiotherapy for oropharyngeal cancer - PubMed (nih.gov)

Also possibly an alternative anticoagulant?
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4875919
I can only assume but if you are on a fixed dose of Fluconazole then the interaction between the two could be manageable, from an INR of 1.4 to 6.0 I'm guessing is on very different daily doses of warfarin?

 

[goffrey]

Hey Goffrey

that's a great pro-active move.

I suspect its going to be a rocky road for those months, so feel free to reach out if you want a hand managing that. I've been able to tame most INR dragons so far.

The Lancet

Warfarin's primary metabolic pathway involves the cytochrome P450 2C9 isoform, and fluconazole is a strong inhibitor of this enzyme. Avoidance of fluconazole in patients on warfarin is advisable—unless the dose of warfarin is empirically reduced and the INR is closely monitored. ​

if none of that makes any sense then reach out and we can work on this together (and I always encourage letting your medical professionals know you're working with someone and showing them the results).



I would wonder, because so far when most people say this its either wrong or exaggerated. Not saying you don't just sayin "I would wonder"
Best Wishes

 

[pellicle]

only my quote was in this

not sure if that was a mistake or you simply didn't enter what you wanted to say

 

[goffrey]

I know this sounds terrible but I literally do not eat leafy green vegetables at all and I really should! My diet is pretty steady to the point where I will eat the same thing for months. Most of my friends make fun of my "food jags".

I really appreciate the advice and offer of assistance with helping me manage this INR battle!

 

[goffrey]

Perhaps there is an alternative to Fluconazole you can take for the short time you are on warfarin?
I googled alternatives to Fluconazole and Caspofungin is listed as an alternative treatment that doesn't appear to affect warfarin treatment.
Warfarin treatment and antifungal agent caspofungin for severe fungal infection in a patient previously treated with radiotherapy for oropharyngeal cancer - PubMed (nih.gov)

Also possibly an alternative anticoagulant?
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4875919
I can only assume but if you are on a fixed dose of Fluconazole then the interaction between the two could be manageable, from an INR of 1.4 to 6.0 I'm guessing is on very different daily doses of warfarin?

The Fluconazole is a fixed dose of 400mg per day. I started out on the IV Caspofungin and my INR was low and they had me on a dose of 2.5mg warfarin. After starting the Fluconazole and stopping the Caspo my Warfarin climbed from 1.8 to almost 6 in a week and a half. I should add I don't weigh much and lost quite a bit of weight from the surgery. I am also on aspirin along with the Warfarin.
The Fluconazole is a necessity due to the fungal endocarditis. It is the best matched anti-fungal for the type of fungus I had. I spent 1 1/2 weeks on ECMO after the surgery I underwent for that. I was life flighted to Mayo Clinic and spent 3 months up there. So I would rather battle the INR numbers than take a chance on fungus rearing it's ugly head again!

 

[goffrey]

not sure if that was a mistake or you simply didn't enter what you wanted to say

Sorry total mistake! I have been suffering from some "brain fog" since surgery!

 

[pellicle]

Sorry total mistake! I have been suffering from some "brain fog" since surgery!

boy, do I remember that well ... I thought I was ready for the glue factory

 

[pellicle]

I know this sounds terrible but I literally do not eat leafy green vegetables at all and I really should! My diet is pretty steady to the point where I will eat the same thing for months. Most of my friends make fun of my "food jags".

all good ... I've lived on oats, meat cheese and milk for a whole month to test this INR and greens thing ...

I really appreciate the advice and offer of assistance with helping me manage this INR battle!

send me a DM (or PM) when you feel like it and we can chat about it

(*except you click my name ;-)

(I have unlimited calls to Canada and or we can use WhatsApp)

Best Wishes

 

[Chuck C]

Hi Goffrey.

Welcome to the forum. I hope that you are able to get your INR sorted soon.

I had a situation similar to yours, with some big swings in my INR due to being placed on amiodarone, a P450 inhibitor, which I was prescribed upon release from the hospital. In my case the coumadin clinic, the pharmacist and the prescribing nurse all failed to recognize that amiodarone has been shown to cause INR to skyrocket. This effect is well published in the medical literature and, in fact, at my dose of amiodarone, the most recent literature suggested that my dose of warfarin should have been cut in half pre-emptively given the predictable spike that was coming. Now, there are a couple of folks on this forum who claim that only medical professionals can understand published medical literature. While I disagree with this belief, what is certain is that if medical professionals don't read the literature and stay up on it, they will be oblivious to its content. As such, medical professionals, who should have known better, put me in a very dangerous situation by failing to realize that this huge INR spike was coming.

My INR shot from 3.1 to 9.7 after just 3 days. To reverse my INR, I was given oral vitamin K and had it swing down to 1.6 then back up over 5 until things leveled out.

I would definitely take Pellicle up on his offer to help. He really knows what he is talking about when it comes to INR management. He was there for me to offer help during every step of my wild ride and to help me get things stabilized. You just need to be aware that he can be a little hard to understand because of his funny accent.
An, as he suggests, keep your medical team in the loop with the fact that you are getting help and keep them posted on all your readings.

 

[pellicle]

He really knows what he is talking about

but I'm not a medical professional ;-)

You just need to be aware that he can be a little hard to understand because of his funny accent.

and occasional Australian country turn of phrase

 

[Chuck C]

and occasional Australian country turn of phrase

I have an app that helps me out for such circumstances.

It turns out that:

"Get your butt to hospital"

Means

"Get your butt to 'the' hospital"

 

[pellicle]

I have an app that helps me out for such circumstances.

It turns out that:

"Get your butt to hospital"

I can't give you the proper Australian for that ... but here's a small workshop with a hint

 

[pellicle]

Sorry total mistake! I have been suffering from some "brain fog" since surgery!

btw Goffrey, while your waiting for your coaguchek, I suggest referring to this:

http://cjeastwd.blogspot.com/2014/09/managing-my-inr.html
and in particular the label "Getting Blood"

esp:

and perhaps


Best Wishes

 

[mecretired]

I would think that as long as you are on the same amount of fluconazole every day, you should still be able to stabilize your inr. I have been on cephalexin for a year and a half due to 2 bouts of endocarditis and don’t have a problem with my inr.

 

[Chuck C]

I would think that as long as you are on the same amount of fluconazole every day, you should still be able to stabilize your inr. I have been on cephalexin for a year and a half due to 2 bouts of endocarditis and don’t have a problem with my inr.

This was my experience with amiodarone. Due to its inhibition of warfarin clearance, I ended up on a much lower dose of warfarin to keep me in INR range during the 4 weeks I spent on amiodarone.

 

[vitdoc]

I know this sounds terrible but I literally do not eat leafy green vegetables at all and I really should! My diet is pretty steady to the point where I will eat the same thing for months. Most of my friends make fun of my "food jags".

I was thinking about your story trying to understand why you have the fluctuations that you have in your INR. There are at least three main variables that can change. The amount of warfarin, the amount of fluconazole that interacts with the warfarin and the amount of Vit K you ingest and the Vit K your biome makes.
You mentioned that you don't eat green leafy vegetables and that you are thin. I suspect that your fluctuations may be related to low Vit K input so that small variations in your K might cause your INR to vary. So if you ingested more K small fluctuations in your K would be less significant. So if you were to eat a decent salad daily maybe that would smooth out your INR. With home testing that would be easy to check.