NovembINR

[Ola Thoresen]

It turns out that here in Norway, I actually get the test strips for free from the hospital (no, I will not sell them on ebay).
I just received 2 x 24 strips in the mail, and I still have one packet of 24 from my first batch left. Those old strips expire in december, so I thought I'd use those to do an experiment.

I will try to measure my INR every day for the first 24 days of November, and take notes of what I eat and drink, how much I excerecise and other factors that might affect my INR.

Most of the time I will just live my life like normal, and just see how much the INR varies from day to day. But I do hope I am able to do a few experiments to see if some of the "myths" are true (at least for me).

It won't be a proper scientific experiment with well documented procedures, independent test groups and so on, it will be mostly for my self, and I do realize that my experiences might not be universally true. But there are a few questions I hope I will be able to answer after the month is over:

• Does alcohol affect the INR?
  
  How much? And does it matter if I drink red wine, beer or anything else?​
• Do excercise have any effect on the INR?
• How much will my INR change if I try to double the aomount of vegetables I eat? Or half the amont?

Now, I know I can't really change just one factor and I don't have enough time (or fingers) to do this as thorough as I'd wanted, but here is my current plan:

Sun. Oct. 27: I'll do my regular, weekly INR-check, and keep the average of the last weeks as a kind of "base".
Oct. 28 - 31. Write down what I eat, drink and other factors every day
Nov. 1. First day of NovembINR - Self test, and write down all relevant info.

First week of NovembINR - 4. - 10. experiment a bit with wine and beer. Write down what I do, and my INR every morning.
Second week: 11. - 17. Eat "no" vegetabes for a few days, then try to eat more than normal for a few days. Keep on testing every day.
Third week: 18. - 24. Try to do some extra excercise at least two or three days. And also test every morning to see if anything changes.

My currrent plan is to deviate from my regular routines early in the weeks, and fall back to my normal routines in the end of the week. That way I can see how fast my INR will go back to normal after the extraordinary events end.

I can't promise I'll be able to follow this plan 100%, things might turn up. As I said, I am doing this mostly to check what affects my INR of the things I do regularily anyway, but if you have some thoughts about other stuff, just et me know, and I'll see if I can incorporate it in some way.

 

[Ola Thoresen]

The full log:

https://docs.google.com/spreadsheet/ccc?key=0AuMPbkwYwfZpdDkxUXo2NHltU2JSdGxWQUU1blFzNXc&usp=sharing


A summary of some of the premises for this test and some of the questions that were asked:

• I have a CoaguChek XS, and I check it against the lab every time I am there. It has always been +-0.1 or 0.2 of the lab result. The lab is a proper lab in a hospital, doing a full blood draw (they do not just use another CoaguChek as far as I know). This indicates that the CoaguChek is pretty accurate. Anyway - this experiment is mostly about the variation of INR, not the actual value, and the variation will probably be big enough to show even if the meter is not 100% equal to the lab results.
  
• I know some of the changes will take a few days to show up in my INR, so my plan is to change my diet/habits on a Monday, and keep it that way for at least two or three days, and then fall back to "normal".
  The idea is that I should then see a spike - either up or down, depending on the change - in the middle of the week, and then slowly getting back to my baseline during the weekend.
  
• And I also am aware that INR will change anyway. But a just as important result for me would be if I see that sharing a bottle of red wine, or having a few beers a couple of days in a row will not affect my INR more than the normal variance.
  
• Whatever results or conclusions I draw might or might not apply to others. We are all different, and might react differently to IE alcohol, various vegetables with different amount of vit. K, depending on your regular diet and so on. So these results are by no means universally applicable. If in doubt, do your own test.
  
• I use a few arbitrary measurements for "Alcohol", "Greens" and "Exercise" in my original google-spreadsheet:
  For alcohol, I simply count any "drink" as a +1. So a beer is a +1, a glass of wine is a +1 and so on no, matter the size or alcohol%.
  For greens, I use a kind of scale from 0 to 5, where I can give 1 point for breakfast, 2 for lunch and 2 for dinner. 5 means that all meals are mostly based on green vegetables. 2 can imply that most of the dinner was vegetables, or that around half the lunch and half the dinner was green leaves. and so on.
  Exercise also is a scale from 0 to 5, where 5 is what I personally consider a maximum possible workout in a day. 2 is then a moderate workout and 4 is an intensive, but not completely exhausting workout.
  In the graphs below, I simply indicate which days I changed from my regular habits. Not how big the deviation was.

Background

I dose my Warfarin on a weekly basis, and have kept my dosage constant during the whole experiment. As I am a bit lazy, I don't bother dividing the small pills, so I do not take the exact same dosage every day. I use 2.5 mg tablets, and vary between 3 and 4 during the week, following this scheme:

Mon	Tue	Wed	Thu	Fri	Sat	Sun	=
10 mg	7.5 mg	7.5 mg	7.5 mg	10 mg	7.5 mg	7.5 mg	57.5 mg

Since a dose of Warfarin lasts for 2-5 days, with a half time of about 40 hours (http://en.wikipedia.org/wiki/Warfarin) this means that if all other factors were the same, my INR-level would in theory vary between 2.6 and 3.0 according to the following graph:

Of course not all other factors are the same (especially during this experiment, which sole purpose was to test how different external factors will influence the INR-level), but if we add the real INR-levels I measured during the experiment to this graph, there is quite a nice correlation:

There are a few noticeable exceptions, which I will comment on further down. It is worth noting that graphs like these will never follow each other 100%, as I only measure my INR once a day, and the time of day might vary a bit, and also this measurement is a snapshot of that particular time, not an average for that day. So the graph might show a falling line, whereas the INR might in reality be on the way up already because the bottom was reached a few hours before the actual measurement was done.

Now, back to the deviations.

Week one - 2013-11-04 - 2013-11-10

The first week, I wanted to test how much effect alcohol would have on my INR level. The theory was that alcohol would elevate the level, and that it would be a statistically significant variation from the theory-graph. As you can see from the graph above, I started out pretty low, with a 2.4 and 2.3 the first two days. I believe the reason for this is that I had quite a bit of green vegetables the days before (2013-10-31 and 2013-11-01). This explains why the INR-line (blue) is quite a bit lower than the theory (red) - and going down - between 2013-11-01 and 2013-11-02. On 2013-11-03 the level is growing, and staying "high" until 2013-11-07.

Below, you can see the same graph, but with added yellow "dots" for the days I drank alcohol. It seems from this graph, as the effect of alcohol for the first days of November was pretty moderate, but the INR level is staying higher than it should according to theory for at least two days. A really interesting effect happens at the end of the experiment, where I see a much greater effect, with a huge spike in the graph.

The amount of alcohol I drank on this single day (2013-11-21) was not greater than some of the other days, but it still shows a really significant rise in the INR-level. But I did drink more beer and less wine. So this might suggest that it is not necessarily the alcohol itself that is the culprit, but it might be something else that is present in beer, but not in the (white) wines I drank more of early in the experiments. @Protimenow has suggested this as well, as he observes that some red wines will effect his INR level more than other alcoholic beverages. There are several interesting (and possibly quite funny) experiments one could follow up with here.

• Try to drink a lot of no alcoholic beer, and see if that makes a difference.
• Drink only red wine, or only white wine for a few days and check the INR daily.
• Drink vodka (or some other "pure" alcohol) to avoid other chemicals interfering with the results
  I will save this for later.

Week two - 2013-11-11 - 2013-11-17
This week was about vegetables - or more specifically green vegetables. I did not use a vitamin-k-list to plan my meals, as it is a quite established fact that vit. k will lower your INR. I did however eat more of the vegetables I like, and hence is more likely to eat more of in a normal situation as well. The reason was to see how much a diet I could probably live on for a few days would effect my INR, not to see what would happen if I only ate broccoli or spinach for a week.

Here is the same graph, but with green dots for the "extra vegetables"-days.

It seems like vegs has a pretty much instant effect. It will lower the INR, but with my doses, not to a dangerous level. I should probably be a bit careful if I change my diet to a more or less vegetarian only, but with what I would consider a normal amount of green leaves a few days in a row, the INR did not go below 2.3, and quickly recovered to a normal level as my diet changed back.

Week three - 2013-11-17 - 2013-11-24

The last expermient was supposed to look at exercise. I was not sure what to expect, but I thought that heavy exercise would in some way affect the INR. Either make it higher or lower. The graphs do not show anything that suggest either. If anything, they might suggest that the INR is kept more stable, but I do not think this is statistically significant, and is probably caused by other kind of "background noise".

So the most interesting thing to read from the graphs during this last week was that one heavy night out might lead to quite a big spike in your INR, but it will go back to normal in just a couple of days.

Conclusions

These conclusion are NOT universally applicable. These are only my thoughts after doing one single experiment for less than one month on MY body, living MY life. However there are a few nice things that at least makes me feel more confident when I self administer my warfarin dosage.

1. My body recovers quickly, and will get back to a normal level after only 2-3 days, even after a huge spike such as the one on 2013-11-22. Already one day later, I can probably see which direction my INR is going. If I measure an INR-level I feel uncomfortable with when I do my normal, weekly check, I can do another test the next day, and be confident that if the level is about to normalize after this second test, everything is probably fine. If I see an "extreme" result (> 3.5 or < 2.0) more than two days in a row, I will adjust my dosage slightly and do another test a day or two later.
   
2. However, these rapid changes also shows that it is not unthinkable to have huge variations in your INR in just a short time, and that even weekly testing might not pick this up. I still do not think testing more often than weekly should be necessary, as these spikes or drops will be of a short duration, but it also shows that only testing monthly could lead to prolonged periods of being out of range if external circumstances changes.
   My biggest changes from one day to another was +0.8 (2013-11-21 - 2013-11-22) and -0.7 (2013-11-23 - 2013-11-24), but it was not uncommon to go +/- 0.3 from day to day.
   
3. The vegetables I would normally eat cause only a slightly lowered INR. There is no reason for me not to eat a salad, a broccoli puree or a portion of steamed peas with a grilled steak a couple of days a week. Unless I change my diet dramatically, to a more or less vegetarian only, I should not be concerned at all, even if my INR is < 2.5 on a Sunday after having a great Saturday dinner with a lot of vegetables.
   
4. Alcohol is an interesting thing to watch out for. But unless I drink excessive amounts of beer, probably several days in a row, it should not be anything to worry about (INR-wise). After a heavy night out on Thursday, I had a huge spike in the graph with INR reaching as high as 3.8 on Saturday. But already on Sunday the INR was back down to 3.1 and Monday I measured 2.7.

All in all, I feel that this test has proven that self administration is not difficult. As soon as you have found your right dosage, your body will quickly readjust and get back to a normal INR in just a couple of days even if you go crazy with drinking or eating for a day or two. So don't worry about that upcoming holiday season or the anniversary you want to celebrate. Enjoy your life!

But we have seen examples where you might have to adjust your dose, even after having found a "stable" regime: http://www.valvereplacement.org/forums/showthread.php?42132-NovembINR&p=545404#post545404
So if your INR is higher or lower than normal for more than a few weeks, you might want to change the dosage slightly. After doing that, you would want to keep a closer eye on it for a while to be sure you do not over compensate.

Anyway, the effect of both a changed dose or variations in your diet will be pretty instant, and if you do not see anything after 2-3 days, it probably did not have an effect. But that also means you will have to be careful not to make changes based on a single measurement. A few extra pieces of broccoli on Thursday might show up on your Saturday INR-test, but will be totally gone by Sunday. If you are uncertain, try to do tests on different weekdays, as regular habits might influence your INR in such a way that Monday is always lower than average, or Wednesday is always in the high end. Instead of testing weekly on the same day every week, maybe try to test every 6 days for a few months, just to check.

 

[Protimenow]

This sounds like an interesting plan, and it's good that you have enough strips to be able to do this testing.

You didn't indicate which meter you will be using but based on the number of strips (2 x 24), I'm guessing that it's the CoaguChek XS.

One thing that we will all have to realize is that some of the things that you do may take a day or more for full effects to show up (in other words, will a certain wine lower or raise your INR in one day or will it take two days for this to happen?) Although you'll be taking a month to do the testing, you might look at making fewer changes, more often (or not), rather than a different change each day and watching for results the next day.

(Greens - things with a lot of Vitamin K - should get rapid results, because K is metabolized pretty rapidly. Wines, antibiotics, other things that may effect how your liver processes warfarin, or how the bacteria in your gut processes warfarin, or other things, may take longer to see actual changes).

Still, this is an interesting approach, and I'm glad to see that someone will be doing it. (I thought about doing a similar set of tests -- even without making changes, I was interested in the processing time for warfarin in my body, for example -- a few years ago but didn't have the strips on hand to do it. Come to think of it -- I am not using my InRatio, but I have probably 60 or more strips -- maybe, even though this meter is always high, I'll commit one of my hands to testing with that meter every few days to see if it detects changes that may be related to certain foods or activities. I'll still use my XS and Coag-Sense weekly for what are probably more accurate results).

 

[pellicle]

Hi Ola

It turns out that here in Norway, I actually get the test strips for free from the hospital (no, I will not sell them on ebay).

cool!

Glad to see your government is making better use of its resources boom than my country is.

anwya ... your plan seems an interesting one. But if you don't mind me making an observation on your experimental design, I feel you have a problem in answering the questions you wish to answer.

It won't be a proper scientific experiment with well documented procedures, independent test groups and so on

true, but it seems you have a plan all the same. Mostly more than this is just drummed up hoo-har anyway ...

but ... the problem as I see it is that naturally your INR will vary. Without two identical copies of "you" you won't know what was natural variation and what was as a result of activities. However if you start on a really regular diet (meat potatoes bread and milk) for some week or so you may get an idea of how your INR varies ... it its not stable you may not be able to tell.

but aside from that it sure sounds interesting

 

[pellicle]

Reserved for logging and conclusions

I am guessing you are intending to update this post rather than continue the thread.

Have you considered google docs for the spreadsheet?

 

[Freddie]

Hope your fingers survive :smile2:

 

[Eva]

Drinking wine, exercising, eating greens...all will affect INR results. But, you do not need to worry as long as you are steady with the amount you drink, what you eat, and exercise routine. I personally do not like greens much, and I only drink occasionally. So, on the days I binge on greens or feel like a "Mojito" or a glass of wine, I take an extra half mg of warfarin. This has been working well for me.

Good luck. You're already lucky living in your country and not worrying where to buy cheaper strips from!&#55357;&#56841;

 

[Ola Thoresen]

Thanks for the feedback.

To sum up some of the questions:

* I have a CoaguChek XS, and I just had it checked aganst the lab, where it showd a diff of -0.2. It has always been +-0.1 or 0.2 the times I have been there. That is good enough for me. And also, this experiment is mostly about the variation of INR, not the actual value, and the variation will probably be big enough to show even if the meter is not 100% equal to the lab results.

* I know some of the changes will take a few days to show up in my INR, so my plan is to change my diet on monday, and keep it that way for at least two or three days, and then fall back to "normal".
The idea is that I should then see a spike - either up or down, depending on the change - in the middle of the week, and then slowly getting back to my baseline during the weekend.

* And I also am aware that INR will change anyway. But a just as important result for me would be if I see that sharing a bottle of red wine, or having a few beers a couple of days in a row will not affect my INR more than the normal fluctation.

* I will probably use google docs or some other way to present the raw data, but I thought I'd reserve the second post to post any significant updates, so people later won't have to read through the whole thread to find a crucial note.


But thanks again for the support. Hope some of you find it interesting.

 

[pellicle]

Your planning sounds as robust as permitted. I will be interested to follow the results.

As I once said to Jarno, try to do the sides of the fingers that way you have more days before you get back to pricking that finger. 10 fingers = 20 sides I found that the side hurt less and didn't need as deep a setting on my lance tool.

 

[Ola Thoresen]

I have now updated the spreadsheet with the "baseline" after my INR check yesterday.
My INR has been pretty stable between 2.7 and 3.0 the last months, except for one Sunday, where it had a spike to 3,6. I blame a couple of nights out, the week before for that. (It will be interesting til see if I see the same spike during next weeks "alcohol experiment".

I won't start the daily INR-testing before Friday, but will try to update the log every day until the experiment is over.
Day to day observations and considerations will be posted as replies here. More important information and conclusions will be added to the second post.

 

[Ola Thoresen]

A bit early, but a few observations.

Thursday and Friday, I had quite a bit of green vegetables for dinner.
Friday and Saturday my INR was getting a bit low (2.4 and 2.3, which is ~ 0.5 lower than "normal").
Saturday was a birthday-party, with a few drinks. I did not have any alcohol (or green vegetables) on Sunday, but had two beers Monday evening, and today (Tuesday) my INR is 2.8.
I will have a couple of beers again tonight, and tomorrow we will be eating out, so I guess there will be a few glasses of wine with the dinner.
After that, I don't think I'll drink any alcohol for the rest of the week.
My hypothesis is that my INR will continue to rise tomorrow and Thursday (possibly peaking at around 3.5), and then fall back to just below 3.0 during the weekend.

 

[Protimenow]

The effects of the wine will probably be fairly rapid. In my case, wine elevates my INR. I don't know if a dark red wine will have a different effect.

It will be interesting to see your daily journal and daily results -- and especially interesting if your comments help to shed light on the factors that may be impacting any changes in your INR.

 

[Ola Thoresen]

As expected, my INR did go up by a fraction today as well, to 2.9, after two beers last evening. I did have green peas with my dinner last night, which is a good vit. K source, so that might explain why it did not rise even higher. Tomorrow and Friday will be more interesting, to see the effect of a complete dinner with "wine package", which I am really looking forward to.
It will also be interesting to see how long the effect of this will last.

 

[pellicle]

great work!

as we say in Australia "your blood is worth bottling"

Thanks!

 

[pellicle]

Hi

not to imply a contradiction, but my experience is that my INR is unaffected.

The effects of the wine will probably be fairly rapid. In my case, wine elevates my INR.

I only drink Shiraz or Cab Sav ... hard to get darker than that.

I begin to wonder if the effect is the wine or some other chemistry in the wine .. such as preservatives or other things (such as albumin which shouldn't have an effect, but just to name one) that is used in wine production variously in different parts of the world.

We are all somehow different (if yet somehow the same) so this only illustrates that I think self testing is a good thing in determining each persons own metabolism so they can best administer and manage themselves.

 

[Ola Thoresen]

We are all somehow different (if yet somehow the same) so this only illustrates that I think self testing is a good thing in determining each persons own metabolism so they can best administer and manage themselves.

I agree. Although I realize not everyone are able to do an experiment such as this, I think most people should consider doing a few extra tests when going on holiday, changing their diets or in other ways altering their regular routines.

Whether it is the alcohol or other chemistry in wine that makes your INR vary is not really important if you at least know that two glasses of wine X is no problem, whereas sharing a bottle of wine Y will probably boost your INR through the roof. An interesting thing to do if you react differently to different wines would be to test the INR of both yourself and of another person if you share the bottle. Makes me wonder how the INR-level changes in people who is not on Warfarin.

 

[pellicle]

Hi

I think most people should consider doing a few extra tests when going on holiday, changing their diets or in other ways altering their regular routines.

100% agree ... and with the costs of test strips its not really expensive.

Documenting in a spreadsheet is also really important too ... helps you remember it ;-)

Makes me wonder how the INR-level changes in people who is not on Warfarin.

do you have a husband or partner whom would be willing to lend a finger?

;-)

I suspect however without warfarin its going to be very close to 1 most of the time.

 

[Protimenow]

For me, it seems as if Sutter Home Pink Moscato DOES cause my INR to increase. Perhaps it's something in this pink wine, perhaps it knocks my liver enough to make the warfarin more effective.

It's not a major change -- from somewhere between 2.5 and 3.1 to about 3.8, but it IS somewhat noticeable, and relatively consistent. I havent' tried testing after drinking other wines.

According to my anticoagulation clinic, they advise their patients who take warfarin to avoid alcohol.

My blood draw at the clinic a month ago was 3.8; on Monday, their lab said 3.63. To me, this is not much of a deal -- I dropped my dose from 7.5 mg/day to 6 mg/day for a day or two. I had a salad yesterday, so my intake of greens is slightly increased.

I told the clinic nurse that I'm managing the INR - I've dropped my dosage and added greens, and not having as much wine. This DID convince her to allow me to get a repeat blood draw after two weeks, instead of the monthly testing.

Personally, a 3.63 (or a 3.8, as reported on my meter) doesn't concern me a lot. I'll continue to be careful, so that I'm not going to get major bruising if I bump into something.

 

[Ola Thoresen]

What a meal! What an experience!

Just have to brag a bit. We went to Maaemo - a 2 Michelin star restaurant to celebrate my girlfriends birthday (and our engagement a few weeks ago).
10 different dishes (more like 20 if you count all the little tastings and "snacks" they provide in between what is actually on the menu) and 10 different wines, beers and dessert wines. Just an incredible evening with so much creativity, and dishes I've never seen or thought of!

But back to the experiment. Most of the wines were white wines, but a few glasses were red or dessert wines (and two beers). The food was mostly different proteins (meet, duck, fish, scallops...) with accessories like mushrooms, cheese, bread in all shapes and forms and so on. So not too many green vegetables or other sources of vitamin K.

And today my INR was still only 2.9.
Now, this can mean several things. Either the effect comes later - so I will see it tomorrow (looking forward to testing tomorrow morning). Or the effect of alcohol itself is rather small, and the effect I observed a few weeks ago when my INR was suddenly 3.6 after a party, was caused by something else. That 3.6 measurement was done Sunday morning, and the party was on the Friday before. So it might be that the effect of such excesses takes 24-48 hours to reach its peak.

 

[pellicle]

Glad you had a good meal

Just wondering, are you able to put up graphs or is that too difficult for you? You could email them to me or pm me about it if you. liked