Question for Al

[Rich]

Al,
A little over a month ago my INR was 4.4.
A schedule was given to me by the doctor to bring it down, but I though it was too extreme so I did my own.
For days later a re-check had me at 2.5 and then I resumed my normal schedule, the same schedule I've been using for the last nine years.
Unfortunately yesterday's test came back at 4.4.
I didn't believe it and went back to the lab today for another draw.
It came back at 4.7.
I believe all this is due to lack of activity because of the weather, I have not changed my diet, medications or anything else.
The activity will increase a lot beginning tommorow when it is going to get much cooler and drier around here.
Starting today what would you recommend?
Currently I take 5mg per day except Wed and Sat I take 2.5mg.
Thanks in advance,
Rich

 

[LUVMyBirman]

Hi Rich,

I bet you it's the heat. I have been riding higher myself. When we had the last cool snap.....my INR dropped below range. I am extremly active. Also have been working in a 1/2 on the tredmill daily. My novice advice.....eat a nice salad, decrese 1.5 mg for a day. Retest in a week.See you that brings you back into range.

Good Luck!

 

[Rich]

Update for Al from Rich

Update for Al from Rich

Well my cardiologist's office called right after I posted my question for Al.
This doctor is new to the office and in my humble opinion not too bright.
My cardiologist is away on vacation.
This new guy's recommendation is to not take anything today, and then go on 2.5 mg daily for the next two weeks.
That would be about about a 40% reduction in my dosage for two weeks!
At that rate my INR in two weeks would probably be somewhere around 0.5!
Don't any of these people get it??
Thankfully we have great people like Al, and a lot of other experience as well.
If it wasn't for that some of us would probably be dead.
How frustrating.

 

[Rain]

More veggies!

More veggies!

Hey Rich,

Mine has been higher for the last month or so too. Instead of adjusting my dosage I?ve just started eating a lot more greens. It is summer afterall... and I love my veggies. I?m still hanging around 3.5 to 4.0 even eating all the vegetables. Kinda weird.

We?re all different and I?ve just been telling Ross how I hate giving out medical advice... But it if was me that?s what I?d do... lots more veggies and no dose adjustment. See how it looks in a week and then reevaluate.

Good Luck!!

 

[Ross]

I pretty much concur with Rain. I wouldn't skip anything, but I might lower it by another 2.5 mg and test again in a week.

Oh yeah, mine crept out of range too, so it's got to be weather related. I had to back mine off 10% and I'm back in range now.

 

[ShezaGirlie]

Hi there Rich...and a late Happy Birthday to you too! Ok, somebody mentioned carrot juice the other day and I'm wondering how you get pure carrot juice down. Maybe with a little "Russian firewater"? Let us know if you try it and have luck.

And look at Raingirlfriend with that nice 68 degree weather up there. Half way nice day here too since we're only in the low 90's.. Push some cool air down here Rain..

 

[Rich]

Thanks you guys,
I didn't know that heat could also play a part in this.
I know we are not as warm as a lot of places this year, but we have been around 90 or above for many weeks now. That is a little unusual here in Michigan.
Gina you reminded me I have to get off my backside and get back on that treadmill.
Ross that is what I'm going to try, no major adjustments.
It is going to be a little cooler for a few days, so I will get back out there and get busy.
Rain I will ask my wife to make up a batch of my favorite cole slaw, I know it will help.
Janie thank you for the good wishes, I didn't hear about the carrot juice.
Like you said maybe it needs a little something to help get it down.
Rich

 

[ALCapshaw2]

Someone recently posted a link to an article in a medical journal that discussed how INR tends to RISE with high Heat and Humidity.


From www.ptinr.com

For Patients

Summer's heat can impact your INR
Date Posted: Friday, July 1, 2005

Prolonged heat can be as important as vitamin K or medications on your INR

Even predictable medications used with warfarin are affected by patients overall health (metabolism) making it difficult to anticipate the INR to be down the road. Compromises to patient immune systems, stress and fatigue will affect the metabolism of warfarin causing an increase in INR readings. The loss of a spouse for example has frequently resulted in elevated INR readings by the survivor. Clinicians and care providers should be on the look out for life changing events of their patients as potential red flags for changes in INR's.

The package insert of your warfarin lists several environmental factors that affect INR's. Weather has been linked to alter patients INR. While weather is not a direct drug interaction, it plays a role in the foods consumed and metabolism of medications patients use.

The following represents a true story.

Click for larger view (follow the LINK to www.ptinr.com)

The graph above is an actual 30-day graph of the temperature and comfort level for the greater Connecticut area. Fluctuations in temperature and humidity have a profound effect of patients – particularly the elderly. Heat related stress and uncomfortable humidity (dewpoint) typical in the summer season elevates patients' INR. While an occasional hot or humid day will not have a profound effect on a given INR, prolonged exposure to high heat and humidity will stress warfarin patients and INR's can easily drift above target INR levels. The blue line (above) is acceptable at 60 degrees or below for most. While air conditioning offers a safe haven from summer-time temperatures, many patients rely on table fans, ceiling fans, resort to pulling down the shades or decide to “tough it out”.

CASE STUDY : The graph above resulted in an elevation from a patient that went from an INR of 2.4 on July 27th to 4.6 in less than a month (August 19th ). This swing was a result of excessive humidity combined with near normal summer temperatures. The patient had no air conditioning relying on only a ceiling fan. No changes were made to his dose as the heat/humidity wave ended. A week later his INR returned back to 2.3 . All other conditions of the patient were constant.


Hot weather over a prolonged period of time has been shown to elevate INR values - even on the most stable patients. The additional effect of humidity and high dewpoints make it virtually impossible to cool the body and results in the potential for patients to be higher than normal. Patients should: make every effort not to become over-heated, drink plenty of non-alcohol beverages and keep close to their physician's orders while keeping all summer INR tests.

 

[jeffp]

That's it! I'm turning off the A/C in the house. The family can sweat it out. (Was 102 here today). I've been shoveling down the warfarin trying to get my INR up and its been a dead slow crawl - still below target. Heat and humidity, here I come!

 

[Rich]

Thanks Al,
That is a really good article.
Like I said earlier after nine years on 'rat poison' I should have known about this.
I guess back then is why my surgeon told me not to overdo things outside in this kind of weather.
Rich

 

[Guest]

I try to make minimal changes for INRs that are below 5.

I have tried to figure out the relationship between the weather and the INR, but I can't find any relationship. I have a huge database going back many years. My conclusion is that few people spend more than four hours per day outside in the "official" temperature. Most people spend about 20 hours per day at the same temberature (+ - 15 degrees F.) all year around.

If heat keeps people from exercising in the summer then it would seem logical that cold kept them from exercising in the winter.

I have looked at the average INR for January and July for many years. Pueblo has one of the greatest variations in the country (more than 60 degrees difference bet Jan and Jul) and the INR was exactly the same. Brian Gage in St. Louis looked at the same people for a year and found that there was no significant variation between the months. (ie siome people went up but the same number of people went down).

There must be individual variations that can be significant, but I don't agree that there is a direct relationship between the outside temperature and the INR of people who live with heating and air conditioning.

 

[Marty]

10% solution!

10% solution!

Rich, You are the ideal candidate for the tried and true 10% solution. Decrease weekly dose by 10%. . You are taking 30mgm. Decrease weekly dose by 3mgm. Get as close as you can to 27 mgm. How about Sun 5,Mon- 2.5,Tues-5, Wed-2.5, Thurs-5,Fri-2.5,Sat-5, thats 27.5, close enough, then test.Try to avoid the yo-yo!

 

[Rain]

I knew it!

I knew it!

I set the central air at 75 degrees and leave it there all year. But still I do have to AGREE! I swear the weather makes a difference.

Just wait a few years.... the medical journals are going to uphold my theory about the dog in the flower bed.... I just know it!

 

[Rich]

Marty,
That is exactly what I'm doing.
I'm not going to get on that roller coaster!
When my cardiologist returns, I will have a little talk with him about his latest helper.
That guy needs to be educated about this stuff.
He is the same guy my next door neighbor was sent to.
He put him on Coumadin for a-fib but didn't explain anything to him, not even the simplest things like vit k, alcohol, nothing, nor did he even give him a pamphlet to read.
When I told this to my cardiologist he wasn't too happy, and agreed to take my neighbor on as his patient. Now everything is just fine.
Thank goodness for this site and all the knowledgable people on it.
Can you imagine what people might be going thru who don't have the advantage we do?
Rich

 

[loretta]

Inr

Inr

Rich, do you have a mechanical st. jude? I do & I am having a vry hard time staying in range 2.5 to 3.5. I take coumadin not warfarin don;t know if there is a difference. I have a coagucheck machine at home & my dr. has me testing at home every 3 days & then he adjusts my dose. It goes high , low, its crazy. do you test at homw. also i do not know how to get an answer from any one. I write & no one seems to answer me. So I know I am doing something wrong. Can any one help. loretta

Marty,
That is exactly what I'm doing.
I'm not going to get on that roller coaster!
When my cardiologist returns, I will have a little talk with him about his latest helper.
That guy needs to be educated about this stuff.
He is the same guy my next door neighbor was sent to.
He put him on Coumadin for a-fib but didn't explain anything to him, not even the simplest things like vit k, alcohol, nothing, nor did he even give him a pamphlet to read.
When I told this to my cardiologist he wasn't too happy, and agreed to take my neighbor on as his patient. Now everything is just fine.
Thank goodness for this site and all the knowledgable people on it.
Can you imagine what people might be going thru who don't have the advantage we do?
Rich

 

[Karlynn]

Rich, do you have a mechanical st. jude? I do & I am having a vry hard time staying in range 2.5 to 3.5. I take coumadin not warfarin don;t know if there is a difference. I have a coagucheck machine at home & my dr. has me testing at home every 3 days & then he adjusts my dose. It goes high , low, its crazy. do you test at homw. also i do not know how to get an answer from any one. I write & no one seems to answer me. So I know I am doing something wrong. Can any one help. loretta

Loretta, my guess is you are testing too much and doing too much dosage change. It takes up to 3 days for a dose of warfarin (Coumadin brand name) to show up in your INR number. So your dosage changes and frequent testing are doing nothing to stabilize your number.

I home test and do it weekly - which is considered quite often in terms of testing. But I test weekly because my INR has not been very stable for the 13 years I've been on Coumadin. Testing weekly allows me to keep in range better. Every 3 days is going to put you on an INR roller coaster, particularly if dosage adjustments are made each time.

If your doctor is the one having you test every 3 days, I would say he doesn't know much about warfarin management.

Is your INR running too high or two low. Why don't you post some of your readings and dosages so we can see what might be going on?

 

[Guest]

There it is folks, right there in Loretta's post. The most common reason for the INR being hard to manage. "testing ... every 3 days" Another doctor who doesn't have the slightest clue as to how warfarin works. The doc has Loretta going like a puppy chasing its tail.

Loretta, you have to find some way to get your doctor to give you a dose and try it for one week without changing it. Warfarin is a very slow acting drug. The doctor is making changes in your dosing based on the last change that hasn't had time to show up in your INR yet.

 

[Rich]

Loretta,
I do have a mechanical St. Jude.
I test once per month with a poke in the vein.
In the nine years I've been doing this I have had few problems.
I have to agree with Al and Karlynn in your case, pick a dosage and stay with it for at least a week.
Keep track of things that may affect your INR, such as Vit K from green vegetables, medications such as anti-biotics, alcohol consumption, and last but not least is physical activity.
That got me in a little trouble a few years back, the first full year I was retired I really got carried away remodeling our house.
This was opposite of me sitting at an engineering desk for 46 years.
And I think that is what my problem is right now, too much sitting around due to the hot weather.
Rich