Spike for no reason?

[DachsieMom]

So I am usually very good at weekly testing and generally pretty consistent in my results. However, I’ve been working an insane amount of hours, now from home, and got out of my routine. Just tested tonight after a few weeks. First reading was error 6. No clue what that meant. Tried again, and received a 3.8 (different finger). My range is 2.3-2.8. I’m not freaking out, as it’s not crazy high, but I haven’t done anything drastically different so not sure why it’s high. I will report results to my doctor tomorrow. I last had a 2.3 when I tested on April 12. I have been running a tiny bit more than usual - now running 2-3 miles a day, instead of just on weekends - but that would lower it, not raise it. I has a glass of wine a few days ago, which is very rare for me as I don’t really drink. I had shrimp.....again, not typical for me. I guess the wine is the cause! I expect they will lower my dose a bit and ask me to test next week. In the meantime, I will eat some broccoli!

 

[pellicle]

my view is to drop your next dose to half usual, resume on usual test again in a week.

You'll need to eat a LOT of Broccoli to make a difference.

Let us know how you go

 

[LondonAndy]

An 'ERROR 6' message normally indicates test strip interference, such as the test strip being touched or removed during testing, so you were right to re-test - these things happen. On this occasion it is about 3.5 weeks since the last test, so not necessarily a 'spike' but may well be a gradual rise because of diet changes or increased exercise. I certainly find that more alcohol when I go on holiday increases my INR, and also find that often the first thing I know of a cold or more is a rise in INR - how do you feel?

So I would agree with Pellicle - reduce one dose and re-test in a week or so.

 

[Sheenas7]

I also tested yesterday and got 3.8. My range is 2.5-3.5. My doctor said emphatically "Do not test each week". Send me results next week. Also he has me on a dose of 6 on Mondays and Fridays and 4 the rest of the week. I test on Tuesday mornings. He has told me before he does not want me to test each week unless I am taking a medicine for illness like Tylenol. So I increased my greens and I will test next Tuesday. I try to keep my diet even most days. I like salads but use mostly iceberg with a bit of romaine mixed in. Good luck with getting back in range. It is sometimes diet, weather, exercise.

 

[LondonAndy]

My doctor said emphatically "Do not test each week". Send me results next week.

I fear that your doctor is displaying his ignorance here. There are a number of threads on frequency of testings, with @Protimenow most recently saying how an issue such as a clot can arise within 10 days. However, where I would agree with him is not to over-react to a reading that is out of range by a small amount. Usually a small, one-off tweak to the dose will correct it, or if re-testing shows you are still out of range then consider a general adjustment to dose. I test weekly but only inform my anti-coagulation clinic when they require a result, which is normally every 6 to 8 weeks or more frequently if I have reported a bum result, and of course they are there to help if I need.

Also he has me on a dose of 6 on Mondays and Fridays and 4 the rest of the week. I test on Tuesday mornings. He has told me before he does not want me to test each week unless I am taking a medicine for illness like Tylenol. So I increased my greens and I will test next Tuesday. I try to keep my diet even most days. I like salads but use mostly iceberg with a bit of romaine mixed in. Good luck with getting back in range. It is sometimes diet, weather, exercise.

It would be better of the dose could be more consistent, and I think I have read that in the US you have a 4.5mg tablet? Why not take that daily, and a 5mg once a week?

These are just my opinions of course - I am not a medically qualified person, just someone who now has over 5 years experience of managing my INR in the interests of my own health, and of course others have much more experience.

 

[pellicle]

My doctor said emphatically "Do not test each week".

Your doctor is out of touch with modern practices

 

[ScribeWithALancet]

An 'ERROR 6' message normally indicates test strip interference, such as the test strip being touched or removed during testing, so you were right to re-test - these things happen. On this occasion it is about 3.5 weeks since the last test, so not necessarily a 'spike' but may well be a gradual rise because of diet changes or increased exercise. I certainly find that more alcohol when I go on holiday increases my INR, and also find that often the first thing I know of a cold or more is a rise in INR - how do you feel?

So I would agree with Pellicle - reduce one dose and re-test in a week or so.

I would say that LondonAndy is probably correct. I always test weekly. When I have a change of some sort in my diet or get sick, I will test twice in a week to make sure it did not throw me off. For example 1 or 2 eight hour tylenol will boost my INR by about 0.2 but 6 over three days will boost it much higher. An alternative to skipping a half dose is to spread the reduction over 7 days by reducing your dosage by 0.25 or 0.50 mg a day. I got out of a low 2.0 INR by boosting it 0.5 mg a week for two weeks, testing weekly and going to the lab the second week for a parallel test. When the INR only rose to 2.4+-, I boosted by another 0.5 mg per day (daily dose = old daily dose plus 0.5 mg) and it was about 2.8 when I retested in a week and in two weeks (when I parallel tested at the lab). With small dose changes and weekly testing you can stay in the middle of your range and just correct as you notice that you are drifting up or down.

A glass of wine should only affect your INR if you take too much close to when you are consuming the Coumadin. A pharmacist explained to me that your body regards both wine (alcohol) and warfarin as toxins. Thus, the body works hard get rid of both of them. When you take them both at the same time, the capacity for removal may be limited. My doctor suggested limiting my wine to two ounces at a different meal and I have not had issues since. However, a gap of several days should be enough for a total removal of the wine and there should be no competition and thus no effect so the cause of the high INR is probably elsewhere.

There are sulfates and other items in wine, even sugar. Thus, the only way to eliminate the wine as an issue is to get your INR back to the middle of the range, test your INR, drink a glass of wine at lunchtime and then test the next day and a couple days later. You could repeat the test, only drinking the wine at the meal an hour before you take your Coumadin the INR test.

You can test the running the same way. Give up running for two weeks, test your INR once weekly. If it is constant, then start running for three weeks and test weekly and see if your INR gradually goes up, suddenly goes up or stays constant.

Thru all of the above, keep your greens at the same level. My wife built me up to a half cup a day which amounts to 150 ucg to 275 ucg depending on the greens. You could have had a shift from one constant level of greens to a different constant level of greens. Thus, the reason that many recommend to (1) eat a constant level of greens and (2) test weekly so that changes in your K consumption, unknown changes in your Warfarin metabolism and unnoticed changes in your vitamin, mineral consumption are accounted for.

Note: The Coumadin Cookbook by Rene Desmarais and Jean A.T. Pennington's "Food Values" have tables where you can look up the K1 content in food. The research is still out on K2.

Walk in His Peace,
Scribe With a Lancet

 

[ScribeWithALancet]

I would say that LondonAndy is probably correct. I always test weekly. When I have a change of some sort in my diet or get sick, I will test twice in a week to make sure it did not throw me off. For example 1 or 2 eight hour tylenol will boost my INR by about 0.2 but 6 over three days will boost it much higher. An alternative to skipping a half dose is to spread the reduction over 7 days by reducing your dosage by 0.25 or 0.50 mg a day. I got out of a low 2.0 INR by boosting it 0.5 mg a week for two weeks, testing weekly and going to the lab the second week for a parallel test. When the INR only rose to 2.4+-, I boosted by another 0.5 mg per day (daily dose = old daily dose plus 0.5 mg) and it was about 2.8 when I retested in a week and in two weeks (when I parallel tested at the lab). With small dose changes and weekly testing you can stay in the middle of your range and just correct as you notice that you are drifting up or down.

A glass of wine should only affect your INR if you take too much close to when you are consuming the Coumadin. A pharmacist explained to me that your body regards both wine (alcohol) and warfarin as toxins. Thus, the body works hard get rid of both of them. When you take them both at the same time, the capacity for removal may be limited. My doctor suggested limiting my wine to two ounces at a different meal and I have not had issues since. However, a gap of several days should be enough for a total removal of the wine and there should be no competition and thus no effect so the cause of the high INR is probably elsewhere.

There are sulfates and other items in wine, even sugar. Thus, the only way to eliminate the wine as an issue is to get your INR back to the middle of the range, test your INR, drink a glass of wine at lunchtime and then test the next day and a couple days later. You could repeat the test, only drinking the wine at the meal an hour before you take your Coumadin the INR test.

You can test the running the same way. Give up running for two weeks, test your INR once weekly. If it is constant, then start running for three weeks and test weekly and see if your INR gradually goes up, suddenly goes up or stays constant.

Thru all of the above, keep your greens at the same level. My wife built me up to a half cup a day which amounts to 150 ucg to 275 ucg depending on the greens. You could have had a shift from one constant level of greens to a different constant level of greens. Thus, the reason that many recommend to (1) eat a constant level of greens and (2) test weekly so that changes in your K consumption, unknown changes in your Warfarin metabolism and unnoticed changes in your vitamin, mineral consumption are accounted for.

Note: The Coumadin Cookbook by Rene Desmarais and Jean A.T. Pennington's "Food Values" have tables where you can look up the K1 content in food. The research is still out on K2.

Walk in His Peace,
Scribe With a Lancet

I forgot to mention - While “The Coumadin Cookbook” is an excellent reference on the K1 content of foods, it has one bad piece of advice. Their recommendation is to absolutely minimize the consumption of Warfarin. The correct approach is to maintain a constant level. Most people do not do what I have to do. I measure anything that is solid food if it has moderate amounts (or more) of K1 with a chemist’s scale. However, this is because I was prediabetic and have to minimize carbs as well as maintain a constant level of K.
My wife is gracious enough to measure a half cup of greens per night for me. She sticks to the same kind for a week and then switches for a little variety. The half cup amount keeps the variation to about 25 ucg a day. You should not need to go to that extreme. However, a constant amount is needed. Not a zero amount.
Walk in His Peace,
Scribe with a Lancet

 

[Eva]

....... I has a glass of wine a few days ago, which is very rare for me as I don’t really drink.

My system/INR is affected by little amount of alcohol. From experience, when I drink wine or Mojito, I take a smaller dose of warfarin that night!

 

[DachsieMom]

Thanks, all! My doctor had me reduce to 5 mg tonight (I usually take 7.5 mg every night) and I will test again next week.

 

[cuoricino]

I am so grateful for this thread!!

I am a coumadin newbie and I'm having a really hard time with it. All my life I've never been one for consistency in diet, exercise, alcohol, etc. There are times when all I want to eat are leafy greens and others when I go weeks without. Same with exercise. If I'm training for a race, I run 20+ miles per week. Then there could be weeks/months with no running at all.

All this to say, I'm having a hard time regulating my coumadin.

After testing consistently in the low 2's all of April (despite weekly increases of dosage), my INR jumped to 6.25 this week!!

Since I'm a coumadin newbie (only been taking for 3 months) and my regular cardiologist is on the COVID frontlines I have been having difficulty in getting consistent guidance on how to change dosage when neccessary. I obviously ramped up dosage way too much this past week. But looking through some responses on this thread, I'm also guilty of other things... like not eating as much vitamin k rich foods, exercising a bit less this week, more wine than usual. You name it!

How long will it take to feel comfortable in all this. 6+ INR is crazy high and I don't want that scare again (already worked with a Dr. on a plan to get that number down, btw).

My biggest concern is... do I have to start tracking every single thing I eat/do for the rest of my life? How long did it take all of you to get a handle on this?

 

[Sheenas7]

Thank you for all the comments. I will see what happens on Tuesday. My cardiologist seems very strict on this and now is not a good time to change doctors. I have been going to this practice since I was 19 years old. My first open heart was when I was seven years old and was pioneer surgery with 50% survival rate. I began with a different doctor in that practice but he retired after being my cardiologist for 48 years. My second open heart was in 2001. Thank you everyone. I really appreciate this thread too.

 

[catwoman]

A reminder: One out-of-range INR is not a trend. My cardiologist and I agree with that. He says 2 out-of-range INRs are a trend; I lean toward 3. I prefer to ride out an out-of-range INR trend as long as it’s not a drastic trend. With almost 17 years of being on warfarin and 16 1/2 of home-testing, my experience is that my INR settles back into place. I don’t obsess over the blips and I can usually determine why they occurred.

My doctors (cardio & PCPs) have always said fine to weekly testing. With weekly testing, it’s easier to see an up or down trend. It’s more difficult to establish that with monthly testing. Weekly testing gives me peace of mind.
I have taken 5mg (range 2.5-3.5) for almost all of the last 17 years. Except for special situations (prior to colonoscopies which I do have while staying on warfarin, cataract surgery ditto, starting a course of a new drug), I have been in range about 90-95% of the time. I have told my doctors that I am a very boring warfarin patient. The only other oral RX that I take is generic Boniva. I am on eyedrops for glaucoma, but they do not interact with warfarin.

I love salads and eat big salads, with dark green veggies (very little iceberg because it has little nutritional value). I add matchstick carrots, shredded red cabbage, sliced red onion, strips of red, orange and yellow bell peppers and sometimes add chickpeas, ripe olives, sunflower seeds, hardboiled eggs, grilled salmon or other foods. The more colorful a salad, the healthier it is. I make my own dressings (olive oil, canola oil, red wine vinegar, balsamic vinegar, Dijon mustard, herbs, whatever).

I don’t measure out or log what I eat. My goal is to eat grilled salmon twice a week, but sometimes I fail that. I eat more vegetables and fruits than meat and when I cook, I consider the colors of the meal; I want as colorful a meal as possible, as with a salad. The more colorful, the more nutritious.

I stopped saying, “Oh, I can’t eat that, I’m on Coumadin (or warfarin),” about 16 1/2 years ago. I just follow a fairly consistent selection of foods I eat and it’s become a habit for me.

Like I said, I’m a VERY boring warfarin patient.

 

[LondonAndy]

My biggest concern is... do I have to start tracking every single thing I eat/do for the rest of my life? How long did it take all of you to get a handle on this?

Well, I certainly don't log what I eat either, and I give no thought to INR effect - my INR level is fairly consistent, and I rely on a weekly test to see if I need to tweak dose. I don't know if some people are more sensitive to diet changes, or to changes in Warfarin dose, but for me it has largely been a case of gentle trial and error - eg if my INR result is close to the top end of my range I will reduce my dose by 1mg, once only. If I am a bit over, I might reduce the dose by 2mg, once only.

A question for anyone: do we think our Body Mass Index is relevant? I am overweight, and wonder if this "adds stability" to dose, and if someone skinny has more difficulty? Certainly it is a factor for insulin injections for diabetics, but then insulin uses body fat to diffuse into the blood stream gradually.

 

[pellicle]

A question for anyone: do we think our Body Mass Index is relevant?

well absolute body mass it is established as a scalar when dosing in many regimes so mass is, but BMI I'm not sure. I've never seen it mentioned (perhaps I just missed it) and so if it was I think it would be more commonly mentioned.

 

[pellicle]

Not to Catwoman, but I wanted to reiterate this point.

I don’t measure out or log what I eat. My goal is to eat grilled salmon twice a week, but sometimes I fail that. I eat more vegetables and fruits than meat and when I cook, I consider the colors of the meal; I want as colorful a meal as possible, as with a salad. The more colorful, the more nutritious.

its highly undependeable to be pretending that outside a very few foods anything you do in diet (a serving or portion size) makes any difference. Greens is a myth started by people who were well meaning but was not founded in any research. So basically I want to reiterate a tenent of this forum: dose the diet, don't diet the dose.

I'd go one further : ignore the diet does according to what you see as a trend in INR, and as always keep a steady hand on the tiller.

My views in detail here:

http://cjeastwd.blogspot.com/2014/05/inr-management-goldilocks-dose.html
and of course

http://cjeastwd.blogspot.com/2014/09/managing-my-inr.html
So if any bored warfarin addicts want a read I recommend that as a starter.

 

[pellicle]

My cardiologist seems very strict on this and now is not a good time to change doctors.

well your cardio is wrong (edit: or he's simplifying it because he doesn't want to give you the fuller answer). If he (his story) was correct why would during the On-X trials weekly testing have been a key criteria for ensuring that people attempting to remain on a low INR (to make their marketing team happy)?

The ONLY reason that your cardio can hold that view is that it prevents people jumping to wrong conclusions and fiddling their dose all the time and setting up bad cascade effects.

I argue the following:

1. measure weekly
2. take a consistent dose daily (not 2mg then 9mg then 4mg then 2mg, then 9mg ...)
3. only adjust does when you see a trend
4. keep notes (I use a spreadsheet because graphs are handy for seeing trends)

I would be interested to see any supporting evidence for your cardios well outdated view. (by well outdated I mean by about 20 years now).

Cardiologists are seldom experienced INR managers

PS: a longer answer I see that a few "statements" of 4 to 12 weeks are based on this study:
Warfarin dose assessment every 4 weeks versus every 12 weeks in patients with stable international normalized ratios: a randomized trial. - PubMed - NCBI

Let me dig into that beyond the conclusions and observe a few points:

1. it is based on a single setting, one place only ...
2. then this >>250 patients receiving long-term warfarin therapy, whose dose was unchanged for at least 6 months; << : so lets just pick patients who have not had any history of variation for at least 6 months and go to show that they continue to do that for the next 12 weeks ... Hello, McFly?
3. results: >>The percentage of time in the therapeutic range was 74.1% (SD, 18.8%) in the 4-week group compared with 71.6% (SD, 20.0%) in the 12-week group << : well whoopdy doo .. 74% is a poor score. No wonder people are convinced warfarin is giving you increased strokes and bleeds when you get only 74%. Myself with weekly testing I get 96%

Something to listen to:


and that's not news.

 

[DachsieMom]

I typed this whole long response yesterday and I see it’s not here. No energy to retype, so to summarize -

I eat whatever I want, no regime, no watching consistent vitamin k. Other than a few blips like this recent one, I’ve been consistent for my 5 years of home testing. Usually in my range of 2.3-2.8, with the occasional 3.1.
BMI: I am 4ft 10, 100 pounds, low BMI. I take 7.5 mg warfarin per day. A few years ago, I was on 8.75 on some days and 7.5 on others.
Exercise: I noticed when I first started warfarin, during my 12 weeks of cardiac rehab, I might have metabolized it more quickly. I was running pretty intensely and getting more exercise than usual. It was difficult to keep my inr up, but I was also only 5-17 weeks out of surgery. It’s possible that exercise has no or little correlation, but I will need to start some more intense activity to test that theory!

 

[Sheenas7]

well your cardio is wrong (edit: or he's simplifying it because he doesn't want to give you the fuller answer). If he (his story) was correct why would during the On-X trials weekly testing have been a key criteria for ensuring that people attempting to remain on a low INR (to make their marketing team happy)?

The ONLY reason that your cardio can hold that view is that it prevents people jumping to wrong conclusions and fiddling their dose all the time and setting up bad cascade effects.

I argue the following:

1. measure weekly
2. take a consistent dose daily (not 2mg then 9mg then 4mg then 2mg, then 9mg ...)
3. only adjust does when you see a trend
4. keep notes (I use a spreadsheet because graphs are handy for seeing trends)

I would be interested to see any supporting evidence for your cardios well outdated view. (by well outdated I mean by about 20 years now).

Cardiologists are seldom experienced INR managers

PS: a longer answer I see that a few "statements" of 4 to 12 weeks are based on this study:
Warfarin dose assessment every 4 weeks versus every 12 weeks in patients with stable international normalized ratios: a randomized trial. - PubMed - NCBI

Let me dig into that beyond the conclusions and observe a few points:

1. it is based on a single setting, one place only ...
2. then this >>250 patients receiving long-term warfarin therapy, whose dose was unchanged for at least 6 months; << : so lets just pick patients who have not had any history of variation for at least 6 months and go to show that they continue to do that for the next 12 weeks ... Hello, McFly?
3. results: >>The percentage of time in the therapeutic range was 74.1% (SD, 18.8%) in the 4-week group compared with 71.6% (SD, 20.0%) in the 12-week group << : well whoopdy doo .. 74% is a poor score. No wonder people are convinced warfarin is giving you increased strokes and bleeds when you get only 74%. Myself with weekly testing I get 96%

Something to listen to:


and that's not news.

Thank you for all this information. That new drug they mention on the video for mechanical heart valves was (Bigotram or Vigotran) dont know spelling. I would like to look it up. Do you know anything on that?

 

[Protimenow]

The first three months post-op are not the time to set a warfarn dose. Your body is still recovering from the surgery, and its use of warfarin will change.

Pellicle is the expert on INR management.

A few things about INR management:

If you can, keep your diet and activities fairly consistent. This will make it easier to find a dose that works for you. If you go off the consistency thing for a few days, it shouldn't have a lot of effect on your INR - unless, perhaps, you start binging on dark greens.

If you don't have one, get a meter. This wouild make it easier for you to test your INR and to manage it, if you want to manage it.

One of the most important rules for INR management is to make changes SLOWLY. There's no need to echo Pellicle's advice about maintaining the same daily dose (I guess that I just did).

In regards to Vitamin K - I've seen drops in my INR 12 hours after having a lot of Romaine lettuce. I couldn't see any other factors that would have dropped my INR. Perhaps my body processes Vitamin K more efficiently than others. I may try to repeat this 'test' and see if I can replicate the results.

I've taken Vitamin K2 with no effect on my INR. It's been suggested that we should take a level amount of Vitamin K1, adjust the warfarin dose to account for this, and that we'll get the medical benefits from K1 that we would otherwise be missing. This is also supposed to help keep INRs level. Personally, I haven't tried this on myself.