Question about warfarin dosage and your INR's reaction time

[pellicle]

They market that they keep their patients within therapeutic range 70% of the time. In what world is it ok to be in range 70% of the time with a mechanical valve?

Apparently in this world

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7252837/

​

In the ninth National Conference on Anticoagulant Therapy in 2007, approximately 75% of attendees reported measuring the TTR as a quality indicator for their anticoagulation clinics. However, there was a general unawareness that the method used to measure TTR can affect the results. Approximately 65% used the fraction of INRs in range, 15% relied upon the linear interpolation analysis and 10% employed the cross-section-of-the-files method.6​

​

In recent major clinical trials, the numbers have been higher, with mean and median values often in the mid- to high 60% range.​

 

[pellicle]

@ChuckM

this post led me down a rabbit hole over a coffee this morning

It is an established fact that we do not all metabolize this stuff at the same rate and it points to the need, and educational value, of self testing so that you will "know yourself".

and as you can see above there are some weird and whacky ways of determining Time in Therapeutic Tange (TTR, probably so named because 1) three letter acronyms are the goal and TITR just wouldn't look right )

So firstly lets look at this segment of the Dr Schaff talk:



where he mentions the importance of TTR and compares a typical mechanical valve with "his valve"

Next lets look at how I determine TTR.

1. I test weekly
2. I record the data
3. my spreadsheet counts each event over or under
4. I make a percentage of those 52 sample points

I then analyse the statistics

​	​	​	​
​	​	​	​
​	average​	2.5​	6.6418​
​	std dev​	0.3​	0.4​
​	max​	3.4​	7.3​
​	min​	1.9​	5.5​
​	over event​	1​	​
​	under event​	1​	​
​	%age in Range​	96.2​	​
​	​	​	​

to me the event of 3.4 is not of significance but the 1.9 is (although not critical)

The graphical data

If I wanted to (as those clinics surveyed above seem to want to) I could make that 100% TiTR by just taking the 2 week rolling average

But I'm not like that.

Old saying

Lies, bloody lies, Political Truth, Statistics and INR Clinic TiTTR calculations


HTH

 

[Woodcutter]

found this the other day
https://www.ebay.com/itm/304679701937
worth checking out their "other items" too. In case you have one of those "ex lease" ones that came without a battery hatch or front guide.

Thank you for finding and posting this. I acquired one of those quite inexpensive ex lease units as a backup a while back and having the guide cover is convenient.

 

[QuincyRunner]

Pellicle - my daily dosage of warfarin is 7.5 mgs.

 

[pellicle]

Pellicle - my daily dosage of warfarin is 7.5 mgs.

Thanks

Well there goes that conjectured idea.

 

[pellicle]

Out of interest

in particular foods containing Vitamin K, have a rather quick effect on my INR, definitely within 12 hours

What sort of difference do you find?
Have you monitored (say) a day either side?

 

[carolinemc]

I can’t imagine trusting my life to a clinic or testing service here in the USA. Let me quickly give you an example. One of the premier services for managing INR is a company called Acelis. They market that they keep their patients within therapeutic range 70% of the time. In what world is it ok to be in range 70% of the time with a mechanical valve?! None. There is no world where this is acceptable.

https://www.acelis.com/en/healthcare-professionals/inr-patient-care.html
I test at least once a week … but more often I am testing twice a week because $12 a week (the cost of 2 test strips) to catch an issue before it happens is well worth it to me.

I use a lab at my hospital and we use the same machine as those who do it at home, easier for me since we wait while I am sitting right there for the result. And then can tell me how to dose and to make the next finger stick. We do from 4 weeks to 6 weeks if get a good INR. If INR is high, I can go get the blood work done at the other lab at the hospital and wait two hours for the results. And then I go back one to two weeks later. They are professional and do it very well. I feel comfortable with this way. Everyone is different in the USA, to each their own I say. And we stay within 100% range.
And I have a St. Jude's aortic valve. Have a nice day.

 

[sharky7]

So this is the type of info I'm looking for. One's INR shouldn't be negatively affected by a one off dinner, but a week of it maybe so. Alcohol does seemingly affect it as an increase almost immediately though, correct?

I need to look more into buying one. Where would one go in the US to buy one? Casual Google of the Coaguchek said it can only be drop shipped to a medical facility or education facility. I'm pretty sure I'm not wanting to buy one off of Ebay, correct?

Thanks!

Chuck

I just had to reply to something you said when you added the comment about NOT wanting to buy the "Coaguchek" machine from EBAY, I say to that, why not? From being here as much as I have been, and reading as much from here as I have, I believe many here and perhaps even those that have never been here on this website, have done just that! And have purchased from ebay, I did now going on about 2-2.5 years back or so, the new one I bought was $500/new and worth every penny, I would say without any hesitation at all! And it was shipped straight to me and to my home, no middle man as it were.
[I also was wondering sometimes about that though, on the original box that it came it, the words used on it indicated that it, may or should, only be used by "medical professionals", but here we are with now a large group of us that are currently "HOME TESTING", and I believe most of us are in fact not, MDs nor NURSES of any sort.]

And of course EBAY is also my source for strips, and right now about $110 for 24 strips. And as with the machine, the strips, so far so good. a few errors but not enough to force me to look else where for them, I think it is something that I did, so I dont even blame the machine, haste makes waste as they say!

And so here we are left with talking about price, and that sort of thing, to that point I say this! If I was to die tomorrow because I did not home test, and I was only testing thru labs, etc. How much would my life would be worth then, not much, spend the money, keep as healthy as you can and bottom line of course is, once ya health is gone, no amount of money can buy it back. MONEY comes and goes, always has, always will, as it has before us, and after we are all gone! I happen to think that health is the most important thing in life, for without it, ya not worth a plugged nickel, as the saying goes!
SO, if from all that I wrote, if you have any questions for me about any of it, please, I welcome any and all!!!

 

[tom in MO]

I just had to reply to something you said when you added the comment about NOT wanting to buy the "Coaguchek" machine from EBAY, I say to that, why not? From being here as much as I have been, and reading as much from here as I have, I believe many here and perhaps even those that have never been here on this website, have done just that! And have purchased from ebay, I did now going on about 2-2.5 years back or so, the new one I bought was $500/new and worth every penny, I would say without any hesitation at all! And it was shipped straight to me and to my home, no middle man as it were.
[I also was wondering sometimes about that though, on the original box that it came it, the words used on it indicated that it, may or should, only be used by "medical professionals", but here we are with now a large group of us that are currently "HOME TESTING", and I believe most of us are in fact not, MDs nor NURSES of any sort.]

And of course EBAY is also my source for strips, and right now about $110 for 24 strips. And as with the machine, the strips, so far so good. a few errors but not enough to force me to look else where for them, I think it is something that I did, so I dont even blame the machine, haste makes waste as they say!

And so here we are left with talking about price, and that sort of thing, to that point I say this! If I was to die tomorrow because I did not home test, and I was only testing thru labs, etc. How much would my life would be worth then, not much, spend the money, keep as healthy as you can and bottom line of course is, once ya health is gone, no amount of money can buy it back. MONEY comes and goes, always has, always will, as it has before us, and after we are all gone! I happen to think that health is the most important thing in life, for without it, ya not worth a plugged nickel, as the saying goes!
SO, if from all that I wrote, if you have any questions for me about any of it, please, I welcome any and all!!!

There are different kinds of Ebay providers. I wouldn't want to buy a machine from a teenager who is surplusing his dead Grandpa's meter that's been taken apart by his younger brother and thrown at the barking dog by Grandma.

You should buy electronic medical equipment and their supplies from authorized providers if only to make sure you get the recall notices.

 

[sharky7]

There are different kinds of Ebay providers. I wouldn't want to buy a machine from a teenager who is surplusing his dead Grandpa's meter that's been taken apart by his younger brother and thrown at the barking dog by Grandma.

You should buy electronic medical equipment and their supplies from authorized providers if only to make sure you get the recall notices.

Not sure why you seem to be throwing EBAY under the bus, and thru the years I have had bad things and good things happen using EBAY! And I would add to that, for real, nothing in life is 100%, and or perfect, and I would never claim that anything was! It is a fact that at least 35% of us here have indeed dealt with EBAY and have bought something online at sometime. Has anyone here ever been scammed, perhaps. I have and I have learned from it, and for me, my choice has been EBAY. SO, if ya do ya homework, and get some assistance, using a buying online, EBAY, can be a very good thing, and a way to even save some money!
And here we are, everyone making their own choice to either show online, or to not shop online, and if they are scammed for whatever reason! It gets out in time and more are made aware of what happened, and people learn and move on. And about that recall, I believe it covers everyone, all one needs to do is, once in awhile if they are that worried about it, there are sites where they may find out if there has been one or not!
Here is one place to go for some recalls>>>>> Recalls, Market Withdrawals, & Safety Alerts | FDA
good luck everyone, and PLEASE everyone have an awesome and very healthy 2023!!!!

 

[QuincyRunner]

Pellicle - As an example (and I have done it so many times that I don't even document it anymore), if I have a cup of cooked broccoli on Sunday evening after recording an INR over 3.5, I can expect my INR to drop about .3 by the time I check it again the next day. I continue my normal warfarin dose unless my INR is over 4.0 and if that is the case I take a one-time reduction in my warfarin dosage from 7.5 to 5 mgs in addition to the broccoli. This higher INR will happen if I have failed to have my normal 2-3 big salads over the course of the previous week. If I remember to have those salads my INR will always be in range unless I am temporarily taking antibiotics. I do not consume alcohol, not because of its effect on INR, but just because I never have. Guess I told you more than you wanted to know....

 

[sharky7]

Pellicle - As an example (and I have done it so many times that I don't even document it anymore), if I have a cup of cooked broccoli on Sunday evening after recording an INR over 3.5, I can expect my INR to drop about .3 by the time I check it again the next day. I continue my normal warfarin dose unless my INR is over 4.0 and if that is the case I take a one-time reduction in my warfarin dosage from 7.5 to 5 mgs in addition to the broccoli. This higher INR will happen if I have failed to have my normal 2-3 big salads over the course of the previous week. If I remember to have those salads my INR will always be in range unless I am temporarily taking antibiotics. I do not consume alcohol, not because of its effect on INR, but just because I never have. Guess I told you more than you wanted to know....

I have learned so much from this site, and from you, thank you for explaining the way that you did, it was very detailed and covered much of what I didnt as of yet know, but now i do! I happened to think a salad is and should be part of a diet, and it is hard to keep up with eating one on a regular basis, so i home test, and eat salad when it dawns on me to eat it, and my way of doing this is after a meal if it is close to lunch or dinner time, or i just have a large SALAD as my meal, even though there are a few out there that dont like salads as real food, but i enjoy a salad as a meal, maybe i should add some meats to it? and with that said, please dont cut back, if anything add to your posts for me and those that think like me, which i ponder is most of the regulars here, although i have been known to be wrong sometimes, not often, but sometimes! HHO
thank you!!!

 

[Mister_James]

I can’t imagine trusting my life to a clinic or testing service here in the USA. Let me quickly give you an example. One of the premier services for managing INR is a company called Acelis. They market that they keep their patients within therapeutic range 70% of the time. In what world is it ok to be in range 70% of the time with a mechanical valve?! None. There is no world where this is acceptable.

https://www.acelis.com/en/healthcare-professionals/inr-patient-care.html
I test at least once a week … but more often I am testing twice a week because $12 a week (the cost of 2 test strips) to catch an issue before it happens is well worth it to me.

I think you are reading it wrong. 70% is a great stat but understand what it means. My doctor set my INR range narrow - 2.5 to 3.0. I am supposed to be 2 5-3.5, if I report 3.2 I am out of range and they will have the doctor call me. So I know ignore my actual results and report 2.7 to 2.9.
My INR is anywhere from 2.2 to 4. I have never been too out of range but that's my $0.02.

 

[ChuckM]

I just had to reply to something you said when you added the comment about NOT wanting to buy the "Coaguchek" machine from EBAY, I say to that, why not? From being here as much as I have been, and reading as much from here as I have, I believe many here and perhaps even those that have never been here on this website, have done just that! And have purchased from ebay, I did now going on about 2-2.5 years back or so, the new one I bought was $500/new and worth every penny, I would say without any hesitation at all! And it was shipped straight to me and to my home, no middle man as it were.
[I also was wondering sometimes about that though, on the original box that it came it, the words used on it indicated that it, may or should, only be used by "medical professionals", but here we are with now a large group of us that are currently "HOME TESTING", and I believe most of us are in fact not, MDs nor NURSES of any sort.]

And of course EBAY is also my source for strips, and right now about $110 for 24 strips. And as with the machine, the strips, so far so good. a few errors but not enough to force me to look else where for them, I think it is something that I did, so I dont even blame the machine, haste makes waste as they say!

And so here we are left with talking about price, and that sort of thing, to that point I say this! If I was to die tomorrow because I did not home test, and I was only testing thru labs, etc. How much would my life would be worth then, not much, spend the money, keep as healthy as you can and bottom line of course is, once ya health is gone, no amount of money can buy it back. MONEY comes and goes, always has, always will, as it has before us, and after we are all gone! I happen to think that health is the most important thing in life, for without it, ya not worth a plugged nickel, as the saying goes!
SO, if from all that I wrote, if you have any questions for me about any of it, please, I welcome any and all!!!

It was more of a question as opposed to shoo'ing it off. However I'd probably lean towards Tom's thought, that you never know what you're going to get on Ebay. The Coaguchek market may be a bit more reliable than the cheap chinese knockoff electronic part market that I routinely deal with from Ebay. If its certified new, all the more better, I'm for a deal. But for now my doctor and as of this morning, my clinic nurse, has really pushed the routine diet, medication schedule that she's set and routine testing in the lab.

I'm still interested in purchasing one, but for the time being it would be for my own information (unless I detected a giant swing, in which case she'd call me in to immediately test to confirm and adjust if necessary). So I'm looking at settling for a "hybrid", they'll test to adjust my meds, but I'll run weekly checks to make sure I'm staying within TR for the next 3 weeks. I really just need to find the right machine and buy it.

 

[pellicle]

Hi
thanks for the example

if I have a cup of cooked broccoli on Sunday evening after recording an INR over 3.5, I can expect my INR to drop about .3 by the time I check it again the next day.

wow, that's impressive. Yet the experiments I've done (and the gym guy too) suggest that 400g of spinach (higher in vit K) doesn't move our INR at all

this really does make my mantra of "test and know thyself" more of an axiom of INR self management.

I continue my normal warfarin dose unless my INR is over 4.0 and if that is the case I take a one-time reduction in my warfarin dosage from 7.5 to 5 mgs in addition to the broccoli.

I'm a bit unclear, are you sort of suggesting that you're taking the broccoli as a way of dropping INR (as a point management tool) ? Then if that doesn't drop it you do a single dose adjustment (as a slightly larger hammer to bring it down (under the assumption that its just a FN why its high point not a trend)?

Sorry, you know I just can't help but ask about these things because "that's how I learn"

 

[QuincyRunner]

Sharky7 - Thank you for the kind words. It pleases me to know that something I said is of benefit to someone else. My salads are also a complete meal, most often with either grilled chicken or salmon on top. BTW, we share the same valve in the same position, making us a minority on this forum.

Pellicle - You surmise correctly. I use broccoli like a quick acting, healthy medicine, so it IS a key management tool in my warfarin arsenal. I use broccoli as my first line of offense, rather than higher vitamin K foods such as spinach and kale, simply because I do not like them. I realize that in this instance I am dieting my dose rather than dosing my diet but it works for me. When my INR is above my comfort level (over 4.0) I briefly reduce the warfarin dose as a longer term backup to the front-line broccoli forces already at work. Also to head-off any possibility that the INR increase might be starting a trend rather than a one-off. Your hammer analogy is right on. I should add that I have a very fast and efficient metabolic system. I have always processed very quickly anything that I consume, with both bad and good effects. Sometimes people say they are overweight due to a slow metabolism. Well, I am thin and very energetic. My digestive system is very efficient and I have never even been constipated (save the weeks following my OHS). I also eat very little red meat which tends to slow everything down. Well, that is my story. And by the way, I manage my own dosage without my doctors knowing about it. They tend to freak out over what I consider to be minor INR variations and almost always would recommend drastic warfarin adjustments that would do more harm than good.

 

[pellicle]

Hey, thanks for that

And by the way, I manage my own dosage without my doctors knowing about it. They tend to freak out over what I consider to be minor INR variations and almost always would recommend drastic warfarin adjustments that would do more harm than good.

And sadly this is more common than it should be, I wish more people took solid interest in their INR and its pretty tragic that we even have to fight doctors who remain disinclined to follow the medical literature on this topic. Always makes me wonder what else they are out if touch about.

 

[Protimenow]

Chuck - someone on this site sent me a unit - I still owe them shipping charges! - but I can sure pass it along to you. I never fired it up - insurance supplied me one and I have been testing weekly ever since. Thought I may have skewed my results with a lot of skiing over the past week including in frigid cold at Killington - but the test today was 3.1, Within my 2-3.5 range.

I think I'm the person who sent the meter. If I was worried about the shipping costs, I'd have asked for reimbursement. If you have a machine that you can send to Chuck, please feel free to pass it forward.

Also - regarding this thread, I usually test weekly - I used to be more religious about testing the same day of each week - but not quite as much lately - I'm not sure why.

My adjustments are usually by .5 mg - NEVER with a change of 2.5 mg (as was originally asked about). Warfarin has very significant effects - changes should be kept low.

As with others, occasional changes to diet don't really do much to change my INR.

Plus, FWIW - according to an old study at the Duke Clinic, it takes days (probably a week or more) with an INR below 2.0 to form a clot that could cause a stroke. In my case, I had a Hemosense meter (removed from the market on FDA orders) that was giving me a 2.6, caused a TIA, and the hospital test gave a 1.6.

I'd trust a CoaguChek.

If I were you, I'd test weekly.


A test - whether weekly or monthly - is a snapshot of your current INR at the time you test. It is helpful to have more frames to view so you can catch interim changes before they become a problem.

 

[Protimenow]

found this the other day
https://www.ebay.com/itm/304679701937
worth checking out their "other items" too. In case you have one of those "ex lease" ones that came without a battery hatch or front guide.

There used to be a lot of these machines. Apparently, they remove the battery cover and strip guide (maybe at Roche's direction, to disable them) before they sell them on eBay. Roche support doesn't seem to have any issues sending you replacement strip guides (and probably battery covers) if you call in and ask for one.

I bought a few of these meters - I'm not exactly sure why, because my old meter still works fine. One of the two meters was actually practically new - it had the plastic over the display and just a few tests in its memory. Another had a small scratch in the plastic cover. Both were fully usable once a strip guide (or a used strip) was placed into the strip opening. I didn't care about the battery cover - batteries are usually held in pretty tightly.

 

[Protimenow]

Hey, thanks for that


And sadly this is more common than it should be, I wish more people took solid interest in their INR and its pretty tragic that we even have to fight doctors who remain disinclined to follow the medical literature on this topic. Always makes me wonder what else they are out if touch about.

I have the same doubts about doctors and clinics not having a clue about INR management or how warfarin works. They have no idea how quickly an INR can return to range after a person restarts it (about 3 days).

Two years ago, I had an attempted ablation (the doctor couldn't find the node that caused my PVC - because it wasn't there - my PVC was a result of cardiomyopathy) - he insisted that I use Lovenox the day of the procedure and for the next few days. I don't think it was necessary - they gave me heparin before the procedure, and in three days, my INR was back in range. (Now, rethinking it, if there was risk of a clot forming after the procedure, perhaps Lovenox WOULD have been a good idea).

On the whole, I am still surprised by the lack of knowledge of warfarin management among professionals (many go by outdated thinking - 'avoid foods with Vitamin K AT ALL COSTS' for example - or using ancient dosing guides