NovembINR

[Protimenow]

Right.

I don't see much value in testing daily, and it's not always easy to tell when the results of a particular dose have the most impact on an INR.

For some time, I've been pointing out to some people who don't take the same daily dose that depending on the day that they test, the INR will be different as a result of a particular dose a day, or two, or three days earlier. I tried to point out that if the testing isn't done on the same day each week, there may be a variance that actually reflects the fact that a different dose was taken on a different day. (In my distant past, I took 5 mg on days with a 'T' in their name, and 7.5 mg on the other days. This may have kept me in range - but would have yielded somewhat different INRs depending on which day I tested my INR). This is one of the reasons I like to encourage people to take the same dose each day, if possible. It may not put you into a danger zone on some days and pull you out of that zone on others, but it should keep your INR more consistent, day to day.

When I was finally able to self-test, I also decided that I should try to keep my doses the same (or almost the same) every day of the week, and to NEVER miss a dose. I also saw the flaws in the 'logic' of 'total weekly dose' when it was misinterpreted to suggest that you can make major changes from day to day as long as the weekly total is where you want it to be.

As far as the effects of other things -- I find that greens or doses of Vitamin K have a pretty rapid effect on INR. This is why they use Vitamin K as an antidote in cases when an INR is WAY too high. So -- having those two extra dark green salads could, conceivably, reduce the effects of the warfarin you took two days ago, yesterday, and maybe even this morning.

This whole thing with anticoagulation is still one that doesn't seem to be fully understood. It's one that many medical professionals seem to have learned once, decades ago, and haven't caught up with current understanding of the processes. It should not be hard to find medical professionals who still believe that any source of Vitamin K should be strictly avoided. It certainly isn't hard to find medical professionals who are comfortable with monthly testing or, for those who happen to have 'consistent' INRs two months in a row, who are comfortable with testing every two, or even three, months.

It seems to be a bit of a shame that individuals have to run tests comparing machines, or tracking daily dose and INR against diet and habits; when actual professional research can probably fill the gap that some of us are trying to fill, using our own fingertips and our own limited resources. (Ola used extra test strips, I used multiple meters and strips that I bought for the extra testing).

I can certainly understand why a test comparing meters to lab results would be hard to make happen -- much of the testing may be contracted out to a particular manufacturer, and it wouldn't be a good thing to make that sponsor look bad, would it?

 

[pellicle]

I don't see much value in testing daily, and it's not always easy to tell when the results of a particular dose have the most impact on an INR.

for normal life I would agree, but for the purposes of seeing what happens in more detail clearly its the minimum. By taking measurements frequently you can get some better data. From the data then you can assemble information and think about what it means.

Sure there's lots of what iffs, but I see it as only a benefit to have the knowledge. The worst thing you can find out is "that more research is needed" ;-)

 

[Protimenow]

Agreed..it may be possible to see trends developing..especially if you slightly vary the dose (or another single factor) that may suggest the reason for a fluctuation, if any.

 

[Ola Thoresen]

Thank you for some great input.

@Protimenow you are probably correct that checking every day is not necessary. So far, the biggest change I have seen from one day to the next is +/- 0.3, but that seems to happen pretty frequently (both up and down), so I would not be surprised to see even bigger differences from day to day.

My main goal is to see how fast the body "recovers" after doing things are not part of my normal routine (and surprisingly often I do things that I thought I hardly ever do).
And also see if i can find any simple changes I could do to be even safer and more confident that what I measure is the most reasonable thing to measure.

As it seems right now, it could maybe be wise to change either my dosing scheme, or the day of week I normally check my INR. I currently test every Sunday, but according to my theories my INR would be lowest on Saturday, and maybe as much as 0.3 higher on a Sunday than the day before (due to the increased dose on Friday).
So maybe I should change my plan from 10mg on Monday and Friday, to 10mg on Tuesday and Saturday instead. That way my prediction is that Sunday will be the lowest in the week, and it makes sense to measure at that point - at least if the main concern is to stay above the lower limit.
I would like to keep this as hassle free as possible, and dividing the pills will just make it a bit more work every week.

And then, all the other factors are coming in. So I think that as long as the theoretical max/min of a scheme is well within the boundaries, and I normally stay in range, this is "good enough" for me.
Making it more difficult will only lead to trying to over compensate for natural variations and external factors I can not really control, and that is probably a bigger danger than i slight fluctation in the INR-level from 2.6 to 3.0 during a normal week.

 

[pellicle]

Hi

My main goal is to see how fast the body "recovers" after doing things are not part of my normal routine (and surprisingly often I do things that I thought I hardly ever do).
And also see if i can find any simple changes I could do to be even safer and more confident that what I measure is the most reasonable thing to measure.

if nothing else the whole exersize is excellent training for anyone starting warfarin. You learn so much (technique, outcomes, documentation) that there are only plusses from it for a small investment in strips.

 

[Protimenow]

The main concern is, of course, staying in range. For me, of maximum importance is that my INR is ABOVE the minimum, and I try to keep it above 2.3 or 2.4 (on my Coag-Sense meter - with a CoaguChek XS or InRatio, that reported minimum would be higher because I find that these meters seem to report higher than actual at these lower levels). Keeping the INR below 3.7 or 3.8 is a secondary goal (although, again, only the Coag-Sense seems to slightly underreport INRs, while the other meters, especially the InRatio, seem to lose their accuracy above 3.2 or so). Yes, with an INR above 3.5 or so, the bruising can get worse, and with an INR that is WAY above 4, there IS risk of internal hemorrhaging.

For my own purposes, using my Coag-Sense, I shoot for values in my range. With the CoaguChek XS, I usually look for a range between around 2.5 and 4.0 (because of overreporting issues). I don't even bother with the InRatio any more - although I have more than a years' worth of InRatio strips, I seldom use that meter, and only use the meter to see how much HIGHER than the labs or Coag-Sense it is reporting.

I'm not sure that testing one day after dosing will give you an INR that represents the maximum effect of your dose. You may do better by waiting another day or so because warfarin's effect is very slow acting.

 

[Ola Thoresen]

Eating quite a bit more vegetables than I usually do have certainly lowered my INR, but not dramatically. Down 0.3 points yesterday, and 0.3 more today, means I went down from 3.1 on Sunday to 2.5 today. Depending a bit on other factors, I expect to see 2.0 - 2.2 tomorrow.

 

[Ola Thoresen]

INR was still 2.5 today. Now, this might be because the salads and other ingredients I have eaten does not have a big effect on my INR level. Or it could be that the delayed effect of the warfarin dose previously discussed is more or less countering the effect of the vegetables.

I am testing several different theories and creating graphs of them (INR-Theory X). They all seem to match quite well, but I will do some minor adjustments to them to see if I can find one that is more accurate than the others.

 

[pellicle]

Have you checked the vitamin K contents of the vegetables? If it isn't high it will have no effect.

I am testing several different theories and creating graphs of them (INR-Theory X). They all seem to match quite well, but I will do some minor adjustments to them to see if I can find one that is more accurate than the others

My own observations were that I found two outer limit ranges which described my high and low readings inclusively and used that to give me a zone.

Of course I only use this to scratch my head about what to do with missed doses and whatnot. Ultimately I'm never predicting much. In guess like you the real purpose is to improve my understanding of how my body reacts so that I developed a mental heuristic quickly that is solid.

 

[Protimenow]

It's definitely hard to predict what a particular activity, or food, or drink, or whatever will do. This is made even more difficult when the medication that you're balancing everything else against takes a couple days to exhibit effects; and when the food or drink has unknown levels (although you can guess) of Vitamin K or other factors that may effect your INR, and when you probably don't have EXACT amounts of these things that may be helpful in predicting effects, and when whatever you take or do may take varying amounts of time to show the effects (which also may or may not last a particular length of time).

This is, perhaps, the reason for the logic of staying 'consistent.' When we throw changes at it (and we all do), the INR can change.

Perhaps the guideline should be something about regular weekly testing, unless you're eating or doing things that may require testing a bit more frequently. For me, the bigger fear is that my INR will be BELOW range than an INR that is slightly above range.

It's great to have your own meter. It's also important to check its accuracy against a KNOWN accurate method (if such a thing actually exists). Personally, I'm not uncomfortable with a 2.3-3.5 on my Coag-Sense, or a 2.5-3.9 on a CoaguChek XS. I no longer have much trust in the InRatio. For me, I've sometimes gone more than 7 days between tests (it seems like I'm leaning toward 10 days between tests), but I still feel that it makes more sense to test on the same day each week -- especially as others have also pointed out - because it's hard to really know WHAT effects your INR.

 

[Ola Thoresen]

Have you checked the vitamin K contents of the vegetables? If it isn't high it will have no effect.

The vegetables were typically in the "middle range", so you are right that they are not really high. On the other hand, those are the vegetables that I am most likely to eat, so in that way they are most relevant for me.

What I now feel pretty good confident in, is that salads and other dishes that I eat regularly should not cause huge drop in my INR level. And also that my INR will get back to "normal" in a few days if it goes out of range for some reason.

 

[Ola Thoresen]

Nothing exciting really happens. My INR has been pretty stable in the high end of my range (2.8 - 2.9) for the last 4 days.
Starting to see the end of the project, and my finger tips are looking forward to that...

 

[Protimenow]

As a fellow skeptic, who was willing to sacrifice my fingertips for the sake of science, I understand your discomfort. In some cases, I may have done four (and occasionally 5) fingersticks on the same day (four different meters).

I'm glad to see that you've stayed in range.

(For myself, I will probably have to test a few times a week until my INR is stable again - I just started a supplement that has 50 mcg of K. I don't expect my INR to drop much, and expect that it will be quite stable, but I may have to adjust dosage to accommodate for the Vitamin K)

 

[Ola Thoresen]

Finally something unexpected!

We had a party on Thursday(!) - the company I work for celebrated their 20. "birthday". So that meant free drinks and a late night. Friday was harsh...
BUT - I did have a really high INR on both Friday morning and Saturday. Today, Sunday, it is more or less back to normal again.

Two weeks ago, in my "alcohol test week", I did not see such an elevated INR-level, even after drinking at least the same as I did this Thursday. The main difference was that now I had almost exclusively beer, whereas last time, I had much more wine. Come to think of it, this is in line with the elevation I saw and noted a few weeks before I started this project (where I had an INR of 3.4 on a sunday after a birthday party on the Friday before).

So for me, it seems like alcohol itself might not be the important trigger, but rather something else that is present in beer, but not in wine (or at least the wines I had in the beginning of the experiment).

Another possible explanation is that there is some kind of trigger level, or "step" - so if I stay below that level, "nothing" happens, but if I get above it, my INR will rise really fast.
- And that I was just below that level during the alcohol-week, but for some reason got above it this week.

Anyway, even after being at 3.8 yesterday, I was down to 3.1 again today. So the body recovers pretty quickly. I will do one extra test tomorrow, just to confirm it. Once I have done that, I will do a few more calculations before I write a short conclusion from the experiment.

Thank you for the support during these weeks.

 

[pellicle]

Finally something unexpected!

woo hoo!

I will do one extra test tomorrow, just to confirm it.

drinking during the week is often misunderstood, but when you hit it hard for science its all A-OK

... or did you mean INR test?

Once I have done that, I will do a few more calculations before I write a short conclusion from the experiment.

sounds great. You should also perhaps write up in your conclusions any findings you have had about how this has effected your confidence in self testing and in interpreting your diet with respect to your personal metabolism rather than "one size - fits no one"

 

[Protimenow]

There is also, reportedly, something in red wines that isn't as concentrated (or doesn't even exist) in white wines that may also have an effect on INR. I recently had some Rose wines that seemed to elevate my INR.

Personally, I'm interested in how my body will be reacting to some new vitamins that I just started taking - that have 50 mg (or is it mcg?) of Vitamin K. Unfortunately, the box doesn't say if it is K1 or K2. I'll have a better idea of the impact (if any), once I do my next INR.

I'm encouraged by your willingness to sacrifice your fingertips for science.

 

[Ola Thoresen]

woo hoo!


drinking during the week is often misunderstood, but when you hit it hard for science its all A-OK

... or did you mean INR test?

Unfortunately I meant an INR test. Did an extra this morning, and it showed 2.7, which is in line with what it should be on a Monday according to my theory.

sounds great. You should also perhaps write up in your conclusions any findings you have had about how this has effected your confidence in self testing and in interpreting your diet with respect to your personal metabolism rather than "one size - fits no one"

I have tried to sum up some of the findings in Post #2 now. Will update it a few more times as I look at the stats a bit more.