Reinforcing the need for weekly testing

[Protimenow]

I just checked my INR - it's now 2.3 (even sooner than the full affect of my return to full dosing). I expect my INR to be at around 2.6 tomorrow.

I didn't take Lovenox. I am familiar with how warfarin works, and am aware that 'loading' doses or large initial doses are a mistake. Warfarin doesn't ACT like antibiotics or other medications that use a 'loading' dose to get a quick result.

In my case, when I messed for a couple days before I realized my INR was low, I returned to my standard dose and fully expect a normal INR without Lovenox or any special dosing. (I DID make a slightly increase when I saw there was an error in dosing, but only for a slight, possible, increase based from the anticoagulation that happens before warfarin has its full effectiveness.

Because my INR was only for a couple days, I decided not to do bother with Lovenox.

I can't prescribe this approach, just for liability reasons, but I've stopped with Lovenox if my INR is only low for a few days (like mine was this time).

 

[Protimenow]

Here is my story. Approximately 10 years ago I started having nose bleeds, my INR was within range this occurred three times and each time I went into my doctor who cauterized it. All three times they shot liquid cocaine in the nostril to deaden the pain, and it still hurt so bad I darn near wet my pants. My wife finally did some reserching on line and found that people on warfarin need collegian and which is found in jello, so instead of drinking coffee I switched to hot jello, within less of a month no more bleeds. Now when I blow my nose if I see any drops of blood I will again start drinking the jello.

You mean Collagen? This helped with nose bleeds? I hadn't heard of this.

I'm glad you discovered a way to deal with the nose bleeds.

 

[LondonAndy]

I just checked my INR - it's now 2.3 (even sooner than the full affect of my return to full dosing). I expect my INR to be at around 2.6 tomorrow.

Thanks for the update - I am impressed with your management of the situation, returning to being in range so quickly with what seemed to me too small a booster. I realise that people react to Warfarin differently but even so I think I would take a more cautious approach to correcting a problem like that than I was anticipating previously. It is only by experimenting a little ourselves, with the ability to test when needed, that we can understand what works for each of us, and over compensating can be just as much a problem as under. I am sure the medical profession uses a degree of trial and error in such situations too.

 

[drivetopless]

Curious as to what type of valve you have.. I think that determines the ideal INR level. I take warfarin and a daily baby aspirin. My therapeutic INR is 1.5-2.5 because I have an ON-X valve. 2.5-3.5 would be overkill for they type of valve I have. I did have an INR target range of 1.5-2.0 but it was just too hard to maintain that tightly so I asked to increase the upper limit to 2.5. I’m sure it wouldn’t hurt anything to be at the 3.5 upper limit but nose bleeds, etc could be more of an issue, I suppose. Been doing this for 9 years so far with no issue.
Either way, I’m glad you are back in range and agree with others here...self management is the best. I’ve talked to coumadin clinic folks who don’t seem to know what to do sometimes.

 

[Keithl]

I have an On-X and while the surgeon said I can do 1.5-2.0, but my cardiologist and I agreed on 2.0-3.0 and I try to get around 2.6 and usually float from 2.3 - 3.0 and dipped to 1.8 when I missed a day once. I did not worry when I het 1.8 since I take daily 81mg aspirin as well.

 

[Protimenow]

Curious as to what type of valve you have.. I think that determines the ideal INR level. I take warfarin and a daily baby aspirin. My therapeutic INR is 1.5-2.5 because I have an ON-X valve. 2.5-3.5 would be overkill for they type of valve I have. I did have an INR target range of 1.5-2.0 but it was just too hard to maintain that tightly so I asked to increase the upper limit to 2.5. I’m sure it wouldn’t hurt anything to be at the 3.5 upper limit but nose bleeds, etc could be more of an issue, I suppose. Been doing this for 9 years so far with no issue.
Either way, I’m glad you are back in range and agree with others here...self management is the best. I’ve talked to coumadin clinic folks who don’t seem to know what to do sometimes.

Drivetopless - you've got me a bit worried.
First off - I have a St. Jude Aortic valve. I try to keep my INR around 2.5.
I don't think that the On-X valve was adequately studied so that they can conclusively state that you can't form a clot on the valve (with the risk of stroke or pulmonary embolism) if you keep your INR near 1.5. Keeping your INR around 2.5 WON'T change your life, and would further reduce your risk - even if On-X marketing says that 1.5 is okay.
2.5 is not overkill.
An INR of 3.5 won't give you nose bleeds, it won't turn your urine bloody, it's not the terirble thing that some people may want you to think. Before I was self-testing, a lab (and it could have been wrong) told my doctor that my INR was 7.0 (or so) - the doctor told me to be a bit more careful not to bruise or cut myself for a few days - I had no symptoms. The doctor didn't send me to the E.R. He didn't order packed platelets. He didn't even advise taking vitamin K for a few days.

If it was me, and I had an On-X valve, I'd try to keep my INR in a 2.0 - 3.0 range.

 

[Protimenow]

Thanks for the update - I am impressed with your management of the situation, returning to being in range so quickly with what seemed to me too small a booster. I realise that people react to Warfarin differently but even so I think I would take a more cautious approach to correcting a problem like that than I was anticipating previously. It is only by experimenting a little ourselves, with the ability to test when needed, that we can understand what works for each of us, and over compensating can be just as much a problem as under. I am sure the medical profession uses a degree of trial and error in such situations too.

LondonAndy -- I didn't do anything that should be impressive. Warfarin takes about three days for its effects to exhibit in the INR. This is pretty much the same for everyone taking warfarin - unless, perhaps, there's an underlying liver problem.
The idea of 'booster' dose is not correct (although I DID take slightly more than mydaily dose on the day that I discovered problem). Booster or loading doses are used in antibiotics, where you want to zap infection with a large dose of medication to start knocking it out. Warfarin doesn't work that way - a big 'loading' dose will cause a high INR in three days - and a management problem if you don't know what you're doing.

What I did wasn't trial and error - it was just understanding that, taking my normal dose, my INR should be back within range in three days.

Now - I think I should clarify the reason that I took this approach, rather than quickly adding Lovenox to my course -- my last full dose was on Saturday -- four days later (Wednesday), my INR was probably below two. The following day, I discovered the problem - INR of 1.5. At that point, my INR was probably below 2 for a maximum of two days. When I resumed my full dose, I knew that my INR would be back to normal by Sunday (and, in reality, it was 2.3 two days later). So,I calculated that my INR would be below 2.0 for a maximum of five days - according to some research that I've seen, it takes longer for a clot to form on a mechanical valve. Five days didn't feel like a risk.

I'm comfortable with my INR being below 2.0 for a week or so - much longer than that, and I'd be concerned about a clot. So - if I hadn't checked my INR during the week, and waited another week to test (my INR may, possibly have been 1.5 for a week or so, and it would take a few more days to bring it into range) I probably wouldn't hesitate to use Lovenox.

For this situation, where my INR would have been low for four or five days before getting it back into range, I felt safe just using my normal dose of warfarin.

No magic. No trial and error. No special knowledge.

 

[drivetopless]

Drivetopless - you've got me a bit worried.
First off - I have a St. Jude Aortic valve. I try to keep my INR around 2.5.
I don't think that the On-X valve was adequately studied so that they can conclusively state that you can't form a clot on the valve (with the risk of stroke or pulmonary embolism) if you keep your INR near 1.5. Keeping your INR around 2.5 WON'T change your life, and would further reduce your risk - even if On-X marketing says that 1.5 is okay.
2.5 is not overkill.
An INR of 3.5 won't give you nose bleeds, it won't turn your urine bloody, it's not the terirble thing that some people may want you to think. Before I was self-testing, a lab (and it could have been wrong) told me that my INR was 7.0 (or so) - I was just a bit more careful not to bruise or cut myself for a few days - I had no symptoms.

If it was me, and I had an On-X valve, I'd try to keep my INR in a 2.0 - 3.0 range.

Thanks for the advise. I will take it to heart.

 

[Protimenow]

Drivetopless -- IF you tell your doctor or clinic that you want to increase the range of your INR, and get static, ask this: how will your life change if your INR is 2.5 versus what it will be at 1.5? (The answer is - not much, if any). Of course, if you tell them about increasing your target range, they may go completely off the rails, reduce your dosage, and maybe even make you come in for more frequent tests, just to try to MAKE SURE that you aren't aiming for a higher target range.

If you're self testing (weekly, of course), and self managing, the only thing that you'll need your doctor or clinic for is writing the prescriptions. OTOH - if you test at the doctor's office, they'll see that your INR is 'high' (according to On-X 'recommendations),' so the discussion about where YOU want to keep your INR and where On-X's sales people say you should keep it, will probably be unavoidable.

(Here's a weird analogy that just hit me -- imagine that an INR below 2.0 is like a fire - too much exposure to this fire will cause a stroke or other problem. The On-X has, arguably, better insulation against that fire. The ability hasn't been fully proven, but marketing says that you can get closer to the fire without being burned. So - even though you might be able to get this valve closer to the fire, should you? When millions of people with up to 50 years of positive experiences (using St. Jude and other valves) because they've stayed away from the fire are still around, does it really make sense to flirt with the flames, when it's no more trouble to avoid them? (I hope this makes sense - it just popped into my head)).

 

[Keithl]

One thing I do and have done before my surgery is daily 81mg aspirin and then a fish oil (with over 989mg omega 3 per pill) twice a day, both are supposed to inhibit clotting by making platelets less “sticky”. When I miss a dose I double up on daily aspirin one AM and one PM.

 

[Protimenow]

One thing I do and have done before my surgery is daily 81mg aspirin and then a fish oil (with over 989mg omega 3 per pill) twice a day, both are supposed to inhibit clotting by making platelets less “sticky”. When I miss a dose I double up on daily aspirin one AM and one PM.

Why would you want to do that before surgery (unless you are lowering your INR to 1.5 or so). Your surgeons are probably watching your INR during surgery -- throwing an agent that reduces clotting by making platelets lses 'sticky' may be an unexpected surprise. At least, I'm assuming that you let them know before the surgery.

 

[Keithl]

Why would you want to do that before surgery (unless you are lowering your INR to 1.5 or so). Your surgeons are probably watching your INR during surgery -- throwing an agent that reduces clotting by making platelets lses 'sticky' may be an unexpected surprise. At least, I'm assuming that you let them know before the surgery.

Sorry I meant I was doing it long before surgery. I had to stop all that at least a week before surgery. Basically I was on a regiment for years to help keep my blood “thin” and arteries clean. As soon as I got go ahead after surgery I phased my supplements back in. The fish oil / omega 3 and then daily aspirin help the platelets from “sticking” i.e., clotting. I figure that is a good safety net on top of the warfarin and my On-X valve hopefully help my odds a bit.

 

[tom in MO]

Sorry I meant I was doing it long before surgery. I had to stop all that at least a week before surgery. Basically I was on a regiment for years to help keep my blood “thin” and arteries clean. As soon as I got go ahead after surgery I phased my supplements back in. The fish oil / omega 3 and then daily aspirin help the platelets from “sticking” i.e., clotting. I figure that is a good safety net on top of the warfarin and my On-X valve hopefully help my odds a bit.

My cardio had me on fish oil before AVR, but told me not to take it anymore after my mechanical valve was implanted. He said it wasn't needed anymore since my angiogram before the AVR showed no problem with arterial plaque. He said fish oil interferes with the warfarin and makes it harder to maintain your INR. You might want to run that by your doctor.

Isn't low dose aspirin required for the On-X valve?

 

[Keithl]

Actually there was as mall study that too much fish oil can drive INR up. The study says does lower than I think it was 3 or 4G per day were deemed safe. I used to take over 4G, but now take a little over 2G a day that has high DHA/EPA counts. My cardio only recommended against it as there is some evidence it may increase risk of prostate cancer. I read that study and there (as usual) contradicting studies as well.

 

[Protimenow]

I haven't seen the recommendations for the On-X - but I'm pretty sure that one of their protocols DID include low dose aspirin in its recommendations.

Regardless -- it's safest to maintain an INR of at least 2.0 - even with an On-X valve. The limited studies done with the On-X valve haven't had long term follow up, and we've seen at least one nightmare story of a person who dropped her INR and developed clots.

Current recommendations for mechanical aortic valves give a target INR of 2.5, with a range of 2.0 - 3.0. Years ago, the range was higher. Personally, I'd be comfortable with a value from about 2.3 - 3.5 or so.

A low dose aspirin shouldn't hurt. I've been taking one for years.

 

[Agian]

I take fishoil. I haven't noticed any probs with my inr.
There are some populations that consume lots of fish. They do ok.

Would like to hear opinions.

 

[LondonAndy]

I have taken fish oil since before starting warfarin. Having read that there was an argument against taking this, and that the capsules are no substitute for actually eating fish (which i don't like), i stopp3d for a month and have just resumed in the last week.

I have not noticed any change in my INR as a result, but if I do once a month of being back on it has passed on will update this post.

 

[Keithl]

I think the key to fish oil is making sure you get some that has high epa/dha counts. Most 1000mg piles have barely 300mg of epa/dha. Costco had a Kirkland one that had high concentration, but seems to have dumped it in favor of a Nature's Bounty 1400mg pill that has 980mg of epa/dha. I used to take 2 pills twice a day for years and only stopped for surgery. About 6 weeks after surgery I went to 1 pill twice a day. What I found odd is many of the few reports I saw that did studies would just mention 1000mg pills, but never mentioned how much epa/dha the doses had.

 

[user 16827]

I test weekly & self dose.......

However, to qualify for my prescription i need to email my AC clinic

Today i was 3.0

The clinic advised me i need to test again in 10 weeks
It's solid advice from them and bang on with best practice

 

[Astro]

The clinic advised me i need to test again in 10 weeks
It's solid advice from them and bang on with best practice

That‘s great, you’ll save 9 test strips