Post-op Warfarin

[ETC908]

Hi,
Haven't posted in a bit but I'm 42, otherwise healthy, and underwent AVR with an On-X valve as well as ascending aorta repair on 11/10/21. I had post-op pericarditis and a lot of post-op pain, but otherwise things went well. I was discharged on post-op day 4. At the time of discharge, my INR was 2.0 and the plan was to keep me on the same dose. Because I'm neurotic and I worry, I invested in a home testing kit prior to surgery. So I've been testing every day at home.
After a couple of stable days at 2.0, my INR dropped to 1.8 three days ago, and then 1.4 two days ago. I assume the drop came as my appetite increased, as I ate very little in the hospital and am eating well now. I've been in touch with the Coumadin clinic and we've been increasing my dose. However it remained at 1.4 yesterday and is now 1.3 this morning (we increased it again last night).
I'm optimistic that with these increases it will bounce back soon, but should I be worried about the risk of thrombosis? I'm taking aspirin as well, and have reached out to my cardiologist about the potential for a Lovenox bridge. Waiting to hear back as he has to talk with the surgeon first.
I know there are no firm answers here, but I appreciate the thoughts and experiences of others. I did see pellicle's post about how long one can go without it, and that was helpful. But being acutely post-op here, I'm concerned.

 

[dick0236]

........ So I've been testing every day at home.
After a couple of stable days at 2.0, my INR dropped to 1.8 three days ago, and then 1.4 two days ago. I assume the drop came as my appetite increased, as I ate very little in the hospital and am eating well now. I've been in touch with the Coumadin clinic and we've been increasing my dose. However it remained at 1.4 yesterday and is now 1.3 this morning (we increased it again last nigh

By testing every day you are not giving the most recent changes time to work. As your body, diet, and activity return to normal it is natural that your need for warfarin dosing will increase until you find YOUR normal dose to maintain an INR of 2. I would continue increasing the warfarin slowly to avoid a "roller-coaster" effect. The Onyx valve is designed to operate at lower INR......so that should help protect you until you find your sweet spot. How much is the clinic increasing your dosing?

 

[drleng]

Hi,
Haven't posted in a bit but I'm 42, otherwise healthy, and underwent AVR with an On-X valve as well as ascending aorta repair on 11/10/21. I had post-op pericarditis and a lot of post-op pain, but otherwise things went well. I was discharged on post-op day 4. At the time of discharge, my INR was 2.0 and the plan was to keep me on the same dose. Because I'm neurotic and I worry, I invested in a home testing kit prior to surgery. So I've been testing every day at home.
After a couple of stable days at 2.0, my INR dropped to 1.8 three days ago, and then 1.4 two days ago. I assume the drop came as my appetite increased, as I ate very little in the hospital and am eating well now. I've been in touch with the Coumadin clinic and we've been increasing my dose. However it remained at 1.4 yesterday and is now 1.3 this morning (we increased it again last night).
I'm optimistic that with these increases it will bounce back soon, but should I be worried about the risk of thrombosis? I'm taking aspirin as well, and have reached out to my cardiologist about the potential for a Lovenox bridge. Waiting to hear back as he has to talk with the surgeon first.
I know there are no firm answers here, but I appreciate the thoughts and experiences of others. I did see pellicle's post about how long one can go without it, and that was helpful. But being acutely post-op here, I'm concerned.

No point testing so often. Change in dose is only reflected 3 days later at the earliest. Take 3 days of changed dose, then recheck INR on 4th day morning. Adjust accordingly.

You can ask you surgeon about heparin but likely unnecessary. In fact, you can bleed unnecessarily so early postop. The bleeding can be bothersome even if not life threatening. Don't complicate your recovery unnecessarily.

 

[Warrick]

Its very normal for your warfarin dose to need to increase over several weeks/months after surgery. There are many many references to this fact in the posts here but it might be a difficult one to search out.

I started out way back on 5mg daily, Im currently taking 10.5mg.


@pellicle proberly has references to the need to increase dose after surgery he can post?

 

[pellicle]

Hi

At the time of discharge, my INR was 2.0 and the plan was to keep me on the same dose.

well that wasn't really a good plan, the plan should be to keep you at the same INR

...I invested in a home testing kit prior to surgery. So I've been testing every day at home.

as has been mentioned that's not worthwhile and can be dangerous if you then start adjusting doses based on what you are reading

After a couple of stable days at 2.0, my INR dropped to 1.8 three days ago, and then 1.4 two days ago. I assume the drop came as my appetite increased, as I ate very little in the hospital and am eating well now. I've been in touch with the Coumadin clinic and we've been increasing my dose. However it remained at 1.4 yesterday and is now 1.3 this morning (we increased it again last night).

ok, I'm a little unclear about the timescale here, so what are your doses from discharge to now, and please can you give it to me as a simple list of:
date, dose [,INR]
date, dose [,INR]
date, dose [,INR]
date, dose [,INR]
date, dose [,INR]

where [,INR] is optional if known if not known don't put it in ;-)

I'm optimistic that with these increases it will bounce back soon, but should I be worried about the risk of thrombosis?

well not excessively, because these things happen, but you do need to start shifting that INR UP. This is done by increasing the dose. Normally one increases the dose in response to the inr.

Now, important question: are you totally, 100%, "swear on the bible so help you God" certain you didn't miss any doses or get them wrong? If you say "oh yes" then, please tell me about the multi layered system you have to ensure you don't and how you know you took the right amount (and please don't tell me you're tipping them out of the bottle and taking them directly or I'll have the nurse spank you).

I'm taking aspirin as well, and have reached out to my cardiologist about the potential for a Lovenox bridge. Waiting to hear back as he has to talk with the surgeon first.

a reasonable precaution, but perhaps not needed.

I know there are no firm answers here, but I appreciate the thoughts and experiences of others. I did see pellicle's post about how long one can go without it, and that was helpful. But being acutely post-op here, I'm concerned.

its hard to know the time scales, but as you write " 11/10/21 " I assume this means November 10th 2021 and that you're American, otherwise for the rest of the people on the planet that would mean the 11th of October 2021 (date formats, sometimes they matter).

I know of one person (recent member) who was INR 1.4 for quite some time post op (months). You have to remember that while its not ideal its also significantly better than being INR=1

So, please give a list as above of dates and doses and INR with that if you happen to know it. From that I can look at what the doses are, the INR is and make some sort of suggestion.

As @Warrick mentioned the change in sensitivity to warfarin post operation is well known in the literature, but apparently not by clinics (who are supposed to be managing INR, farcical isn't it)

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6287325/
https://pubmed.ncbi.nlm.nih.gov/19336266/
its late at night here, but I'll check in again in the morning.

Don't panic ...

Best Wishes

PS: the nurse is Ukrainian, mean, doesn't smile and enjoys suffering.

 

[ETC908]

Thank you all very much. I fully admit that I am neurotic and paranoid, and know that I should not be checking every day. Warfarin was my main concern when choosing mechanical valve vs. Ross, and my biggest fear was being subtherapeutic and throwing a clot. Yes, I am American so I apologize for the confusion on dates. My surgery was November 10th, 2021. I have not missed a dose, and am 99.9% sure I have gotten the dosing correct. I have been home every day recovering, my wife and I set an alarm on our phones, and we review the dose together before I take it.
I do not recall if I was given warfarin on November 10th itself. Here are the doses/results that I know.
INRs were checked in the morning, warfarin was given in the evening. I was in the hospital from Nov 10th through Nov 14th:

Nov 11th INR 1.0, Dose 3mg
Nov 12th INR 1.3, Dose 3 mg
Nov 13th INR 1.3, Dose 5mg
Nov 14th INR 2.0, Dose 3 mg
Nov 15th INR 2.0, Dose 3mg
Nov 16th-- I was visited by a VNA on this date. My machine recorded 2.0. Hers recorded 2.1. She communicated her result to the Coumadin Clinic, who then recommended alternating 2mg and 3 mg doses every day. So I took 2 mg that night.
Nov 17th. INR 1.8. I then contacted the Coumadin clinic as I questioned the instructions and thought the dose might be too low. It's a long story, but there was some miscommunication between the VNA and the Coumadin clinic. So the clinic told me to take 5 mg, which I did on the evening of the 17th.
Nov 18th INR 1.4, Dose 5mg
Nov 19th INR 1.4, Dose 7 mg
Nov 20 INR 1.3, Dose 7mg
Nov 21 INR 1.8. Plan is to take 7 mg this evening.

The cardiologist spoke with the surgeon and they agreed to put me on Lovenox for now. The hope is that my INR will be where it needs to be within a day or two.

 

[drleng]

Thank you all very much. I fully admit that I am neurotic and paranoid, and know that I should not be checking every day. Warfarin was my main concern when choosing mechanical valve vs. Ross, and my biggest fear was being subtherapeutic and throwing a clot. Yes, I am American so I apologize for the confusion on dates. My surgery was November 10th, 2021. I have not missed a dose, and am 99.9% sure I have gotten the dosing correct. I have been home every day recovering, my wife and I set an alarm on our phones, and we review the dose together before I take it.
I do not recall if I was given warfarin on November 10th itself. Here are the doses/results that I know.
INRs were checked in the morning, warfarin was given in the evening. I was in the hospital from Nov 10th through Nov 14th:

Nov 11th INR 1.0, Dose 3mg
Nov 12th INR 1.3, Dose 3 mg
Nov 13th INR 1.3, Dose 5mg
Nov 14th INR 2.0, Dose 3 mg
Nov 15th INR 2.0, Dose 3mg
Nov 16th-- I was visited by a VNA on this date. My machine recorded 2.0. Hers recorded 2.1. She communicated her result to the Coumadin Clinic, who then recommended alternating 2mg and 3 mg doses every day. So I took 2 mg that night.
Nov 17th. INR 1.8. I then contacted the Coumadin clinic as I questioned the instructions and thought the dose might be too low. It's a long story, but there was some miscommunication between the VNA and the Coumadin clinic. So the clinic told me to take 5 mg, which I did on the evening of the 17th.
Nov 18th INR 1.4, Dose 5mg
Nov 19th INR 1.4, Dose 7 mg
Nov 20 INR 1.3, Dose 7mg
Nov 21 INR 1.8. Plan is to take 7 mg this evening.

The cardiologist spoke with the surgeon and they agreed to put me on Lovenox for now. The hope is that my INR will be where it needs to be within a day or two.

Unfortunately, the quality of advice given at Warfarin clinics varies tremendously depending on who picks up the phone. I think it's a global problem!

I think it's safe to take 7mg this evening. Your INR check tomorrow morning will reflect the dose of 7mg which you have been on 3 days.

As for heparin, your doctors need to cover their arses by saying yes to it since you asked. (I am a doctor and I was also treated with heparin bridging recently What dose of heparin did they advise? Probably a token low dose... Textbook dose is 1mg/kg 2x/day. 12 days out from surgery... Unlikely to haemorrhage from your wound site but question is is the inconvenience necessary? You are likely to hit INR 2.0 by tomorrow.

 

[Chuck C]

Nov 16th-- I was visited by a VNA on this date. My machine recorded 2.0. Hers recorded 2.1. She communicated her result to the Coumadin Clinic, who then recommended alternating 2mg and 3 mg doses every day. So I took 2 mg that night.

They gave you terrible guidance. Set aside the fact that your own meter came in exactly on target with 2.0, and assume that the nurse's reading of 2.1 was the only number available. With an INR of 2.1, if your target is 2.0, they should not have told you to drop your dose by 33% every other day. Even though it was only a 1mg reduction, that represented a drop of 33% of your normal dose. They should have left it alone at 2.1 and if they somehow felt compelled for some unknown reason to tinker with your dose on odd days, they could have had you drop down to 2.5mg as the pills easily break in half, but even that would represent a 16.67% drop and would have been silly and uneeded with an INR of 2.1.
And, as others have noted, it is well documented that in the months following surgery, generally warfarin dose needs to be increased to keep a stable INR. This was the case for me, as I needed 3mg to 4mg when I was released and within 4 months I was taking 6.5mg per day.

I'm very glad to hear that you are now at INR 1.8 and it is back on its way up. You'll be fine.

 

[user 16827]

Thank you all very much. I fully admit that I am neurotic and paranoid

That is understandable, your INR will settle especially with help from this board from people
who actually use warfarin and understand things ( unlike most Clinics )

your self testing is a great first step, you will soon probably dose yourself and have the confidence to do so
with a little bit of experience.
I've found nobody knows me like me, you will be the same and become your own advocate.

good luck & keep us updated

 

[pellicle]

Good morning

the data

Nov 18th INR 1.4, Dose 5mg
Nov 19th INR 1.4, Dose 7 mg
Nov 20 INR 1.3, Dose 7mg
Nov 21 INR 1.8. Plan is to take 7 mg this evening.

ok I'm going to ignore everything else in that post (but thanks for providing it) because it was a nonsence (not your fault, but the advice of the uninformed it contained).

my guidance

I'm going to say that I think that (looking at the data) the dose of 7mg is perhaps going to be right going forward at least for a little while, but there is to me a significant chance that you'll need to lower it to 5 in the next few days. I would say to hold on 7mg but that once you see INR go over 2.5 to reduce it to 6mg and hold that

We can make a more reliable call as we see the data.

the reasoning

You need to understand a few thing in order to grasp this topic.

1. the intention to treat (the risk of a clot) is INR - only INR
2. the dose you take is the dose that gives you that INR. Nothing else guides dosage determination
3. like lighting a fire in the fire place the house does not become warm immediately, there is a delay. The warmth is what you desire and so that is the comparison to INR. Similarly the delay in the house getting cold when the fire goes out.
4. you build a larger fire at the start (while not burning down the house) and then the fire can balance with how cold it is outside (energy loss)

That's a simplification but sufficient for this job.

I don't recommend you continue taking your INR every day (you're going to run out of fingers) so the most neurotic soothing advice I can give you is every 2 days but I'd suggest 3.

Please follow up with data as you have been doing and we'll see where it goes. For now I'm going to suggest you follow my advice here. However if you follow the Clinics advice (please pass it by me here first) then at best if they are wrong you can use that as a stick to hit them with.

Lastly I'm going to repeat my favourite graph (from this study):

lets set aside for a moment that you have an On-X (I suspect chosen based on your confessed neurotic views which may extend to misunderstandings and partial truths told to you about Warfarin) and ignore for a moment their (not strictly safe) protocol of INR < 2. Instead lets go with what the study shows as the green zone of INR risk management which is above 2.5 but below 4 ... lets shoot for that.

NOTE: You are still very much recent OHS and so the idea of a stable INR is just like the idea of trying to find a smart dumb blonde. So you should expect that at least for now we'll need to monitor, consider and dose.


Best Wishes

 

[pellicle]

PS: @ETC908 , if you would like to work together collaboratively on this reach out with a PM and I can do up a spreadsheet on Google Sheets, make you an editor and we can go from there.

if not that's good too.

 

[ETC908]

Thanks for all of the info, and sorry for the delay in responding. I wanted to get more data before replying again. My INR on Nov 22nd remained at 1.8. So I contacted the clinic and they instructed me to increase to 10 mg. I took 10mg on the 22nd and last night. Yesterday, my INR was 2.1 and today it was 2.6. So thankfully, I am now in range. I spoke to them again today and they calculated that my dose for the past week was a total of 54 mg, so they recommended a similar dose of the next week. She recommended I divide it by taking 7.5 mg on five of the next seven days, and then 10mg on the other two days. So I'll be taking 10mg this upcoming Friday and Monday, and then 7.5 mg the other days. I will re-check on Monday and contact them.
My diet is not back to what it was pre-surgery. I have been avoiding greens since my INR dropped. I also used to have a protein shake every morning after working out, which contains a bit of caffeine (which I have to avoid right now to reduce the risk of A-fib), and Vitamin K. Eventually I would like to incorporate all of that as I return back to "normal", and focus on dosing my diet. For now the goal was to get things therapeutic and somewhat stable. I'm going to start to gradually re-introduce greens again and see how things go.
I appreciate all of the help. As for the On-X valve, I really wasn't given a choice. It's the valve that my surgeon utilizes the most and is most comfortable with. But after reading some of the threads here, I'm going to talk to my cardiologist about keeping my goal INR above 2 long-term, as knowing myself I would not be comfortable in the 1.5-2.0 range.
Thanks again!

 

[pellicle]

Hi

Thanks for all of the info, and sorry for the delay in responding. I wanted to get more data before replying again.

logical and I don't fret over things like that ... after all, its got nothing to do with me ;-)

My INR on Nov 22nd remained at 1.8. So I contacted the clinic and they instructed me to increase to 10 mg. I took 10mg on the 22nd and last night. Yesterday, my INR was 2.1 and today it was 2.6. So thankfully, I am now in range.

that's good ... but I'd still like to monitor it for a bit to see where it goes

I spoke to them again today and they calculated that my dose for the past week was a total of 54 mg, so they recommended a similar dose of the next week. She recommended I divide it by taking 7.5 mg on five of the next seven days, and then 10mg on the other two days.

I'm just going to ask you to read that again and consider for a minute that nobody outside the USA (at least that I've ever heard of) talks about how many mg people take per week. Its absurd when you consider that

1. the half life of warfarin is around 2days (meaning that a dose will cease to be influencing the system by 4 days)
2. they then instruct you to take a dose of mg per day

I understand that its like this with dates, everyone who "grows up with the system" thinks that its logical to write Month/Day/Year when if you wrote a list of days you'd go 11, 12, 13, 14, 15, 16 and not
11, 11, 11, 11, 11, 11 (meaning just the month)

So I'll be taking 10mg this upcoming Friday and Monday, and then 7.5 mg the other days. I will re-check on Monday and contact them.

firstly "what are the other days", secondly, I argue that this is absurd because your accumulated drug level will go like this:

so can you imagine that your INR will not respond to that and it will not matter where then you measure? What if you measured on day 9 after your accumulated warfarin had reached around 25? Would that matter?

it makes no sense when you can take actually very close to that by taking (say) 8mg one day and 7.5mg the next? Dosing like that and thinking in weeks makes it seem logical that you could take 4 days of 10mg and 3 days of 5mg ... that of course would be absurd and the "weekly thinkers" will say oh but of course you just need to average it out properly. So why introduce the complexity when you can just remain thinking in mg per day?

The best thing you can do is to maintain a consistent daily dose because weeks only mean something to people who don't understand biochemistry. Your endocrine system doesn't care what day it is.

My diet is not back to what it was pre-surgery. I have been avoiding greens since my INR dropped.

well firstly you shouldn't avoid greens >dose the diet< do not attempt to meddle with your diet for the sake of the dose (and it will have less effect than you expect in reality.

...For now the goal was to get things therapeutic and somewhat stable. I'm going to start to gradually re-introduce greens again and see how things go.

a so called steady state based on a false premise (an altered diet) will not lead to a steady state. Eat normally and lets work this thing out properly.

I'm going to talk to my cardiologist about keeping my goal INR above 2 long-term, as knowing myself I would not be comfortable in the 1.5-2.0 range.

that's pretty wise.

Best Wishes

 

[Warrick]

So they are saying take 57.5mg a week, up from the 54mg. So 57mg a week is 8.21mg a day and 54mg a week is 7.7mg a day, its much easier and generaly your INR is more stable to think in daily doses not as a lump sum a week.

Curious what pill sizes you have-
https://health.ucsd.edu/specialties...ers/warfarin/pages/tablet-identification.aspxI would have thought perhaps alternating 7.5mg- 8mg each day would give you the 54mg, big dose changes between days( like 10mg- 7.5mg) can make stability difficult.

Here in NZ we have 1mg, 3mg, 5mg which are also different colours to the US. Three pill sizes like that make it much easier to “tweak it” and with breaking pills in half give you any dose you like.
Me Im on 10.5mg so I just alternate 10mg one day and 11mg the next cause I can’t be bothered trying to break pills nicely

Also use of a pill box if you are not already is a must! I load it up once a week so when I get home from work at night its just pop that days lid and down the hatch, also you can see if you have missed a dose which I have managed to do twice in the last 6 years.

 

[pellicle]

@ETC908

Also use of a pill box if you are not already is a must!

I think this bears repeating ...

 

[user 16827]

She recommended I divide it by taking 7.5 mg on five of the next seven days, and then 10mg on the other two days. So I'll be taking 10mg this upcoming Friday and Monday, and then 7.5 mg the other days.

firstly thanks for the update and I'm glad to read you are now within a therapeutic range.

to echo the thoughts of the others, this is not best practise, a steady daily dose will give you a more predictable and smoother curve.

I believe they only use a 7 day total as an example of how to smooth out a curve, 54mg divide by 7 =

so it makes far more sense that we use the mean of the 7 day calculation at the very least.
( or as close as possible using a pill cutter and a combination of pill mg sizes )

This is all aimed to help you

 

[Chuck C]

'm going to talk to my cardiologist about keeping my goal INR above 2 long-term, as knowing myself I would not be comfortable in the 1.5-2.0 range.

I think this is wise.

As it pertains to the guidance that your coumadin clinic has given you. As the chart posted by Warrick indicates, we have a spectrum of warfarin dose sizes, making it really easy to take whatever daily dose is needed, within .5mg, as they easily break in half. I keep on hand 1mg, 4mg and 6mg, which makes it easy to come up with any dose I need.

I would echo what others have said, in that it makes for a much for stable and consistent INR to take the same daily dosage, or as close to it as possible. Right now taking 6mg seems to do the job for me, but, there have been times when I would alternate between 6mg and 6.5mg. Super simple to create a 6.5mg dose, as you just break a 1mg pill in half + a 6mg.

Every now and then we get someone come out of the woodwork and announce that “no one should listen to any of these random people on the internet. Just listen to your doctors and clinics, because they are the only ones who really know anything.” Well, whichever doctor came up with taking sometimes 7.5mg and sometimes 10mg does not know very much about maintaining a stable INR in my view. But, like the others here, I'm just a random voice on the internet, so what the heck do I know? Perhaps the textbook he read told him that you count the weekly total and that is all that matters- who knows?

The weekly dosage they suggested to you comes to 57.5mg. As noted above, if you divide that number by 7, that is 8.21mg/day. If that is in fact the correct amount for you, why would they not have you take 8mg one day and 8.5mg the next and keep alternating, which would average out to 8.25mg/day?

There are people here who have decades of experience maintaining stable INR. In this situation I would give a good listen to these random internet voices and apply a good measure of common sense as to whether having a stable warfarin dose or a dose with large 2.5mg swings makes more sense for stability.

Anyway, very glad to hear that you are finally in range. Please keep us posted.

 

[carolinemc]

Hi,
Haven't posted in a bit but I'm 42, otherwise healthy, and underwent AVR with an On-X valve as well as ascending aorta repair on 11/10/21. I had post-op pericarditis and a lot of post-op pain, but otherwise things went well. I was discharged on post-op day 4. At the time of discharge, my INR was 2.0 and the plan was to keep me on the same dose. Because I'm neurotic and I worry, I invested in a home testing kit prior to surgery. So I've been testing every day at home.
After a couple of stable days at 2.0, my INR dropped to 1.8 three days ago, and then 1.4 two days ago. I assume the drop came as my appetite increased, as I ate very little in the hospital and am eating well now. I've been in touch with the Coumadin clinic and we've been increasing myWi dose. However it remained at 1.4 yesterday and is now 1.3 this morning (we increased it again last night).
I'm optimistic that with these increases it will bounce back soon, but should I be worried about the risk of thrombosis? I'm taking aspirin as well, and have reached out to my cardiologist about the potential for a Lovenox bridge. Waiting to hear back as he has to talk with the surgeon first.
I know there are no firm answers here, but I appreciate the thoughts and experiences of others. I did see pellicle's post about how long one can go without it, and that was helpful. But being acutely post-op here, I'm concerned.

With testing everyday, you are not getting the picture. Home testing is not to be done everyday like a Diabetic who tests glucose everyday. You have to pay thousand for the test strip for the INR at home. Testing everyday is not a great thing when it does not take into account to be done weekly or monthly. That is excessive testing. I hope you have stopped the daily testing, for you need to allow days for the new dosage to adjust in your system. Otherwise the test strips will take up your monthly budget for thousands of dollars for one month. Go by the clinic dosing the warafarin till you are familiar of the process. Good luck in cutting down a bad habit. Overtesting and adjusting dosage daily hurts you more then the heart problem. Please ease up and dose on a weekly, not daily.

 

[slipkid]

I would echo what others have said, in that it makes for a much for stable and consistent INR to take the same daily dosage, or as close to it as possible.....

Every now and then we get someone come out of the woodwork and announce that “no one should listen to any of these random people on the internet. Just listen to your doctors and clinics, because they are the only ones who really know anything.” Well, whichever doctor came up with taking sometimes 7.5mg and sometimes 10mg does not know very much about maintaining a stable INR in my view.....

My first cardiologist & his "team" who monitored & prescribed my INR did not understand the concept of being much safer to try to maintain an even INR (through dosing weekly then dividing by 7) instead of daily doing whatever dosage they happened to decide on in response to my INR resulting in a roller coaster effect. They had me taking something like 3-4x my other daily doses on Mon or Tues, so that I had a yo-yo INR peaking end of the week then falling off a cliff then bouncing way back up. Oh & in addition I would get phone messages from them telling me to increase (or decrease) my dose to X even though I already was taking that amount or was just told by them to change from that like the previous day. THEY HAD NO CLUE AS TO WHAT THEY WERE DOING AND ONLY GOT INSULTED AND SHORT TEMPERED WITH ME IF I TRIED TO DISCUSS THE SITUATION. I had to beg my primary physician to take over the INR "management" and had a discussion with him about it, even showing him guidelines from the Cleveland Clinic (which my cardiologist's people refused to even look at!), which he agreed with and acknowledged that the dosing should be as consistent as possible, and to aim for a consistent INR, not one bouncing from below range to above range.

There was a lot more to this as well which shocked me regarding the misinformation this cardiologist was involved in that I won't go into, other than to say that this was just one of literally HUNDREDS of medically nonsensical situations I have been put in over the years, and anyone who BLINDLY follows their Dr's instructions is quite frankly a fool.

 

[perrybucsdad]

I really frustrates me when I see a clinic making what I consider big adjustments (anything more than 10%). I don't recommend self adjusting, but you need to have an idea of what the adjustment should be. There has been some outstanding advice on this forum, so listen to what is being said and you will learn over time. We all were there at one time.

I will give one piece of advice that my cardiologist gave me when I received my valve. He told me that I didn't need to avoid any foods (e.g. salads, spinach, other high Vit k foods). He just said to eat them consistently. I now eat a spinach salad every day. Or, you could say you will eat one every other day. Just do it consistently in a shorter time frame.

Are we allowed to share a nomogram on the forum for dosing? I don't want to violate anything, but it might be good to share just for education purposes. I have one from the Cleveland Clinic, but I don't want to post unless it is okay.