Trouble with levels - exercise theory

[Phil]

Hi all,

I seem to be having trouble maintaining my INR levels. Post surgery when I was not exercising much my levels were pretty consistently within range. However, since exercising much more my levels seem to be very low. The last four tests results have been 1.7, 1.4, 1.6 and 1.4, despite my diligence with being consistent with my green vegetable intake. Have others experienced this? I have only been on warfarin for 10 weeks so maybe it's just a teething issue.

Your comments appreciated.


Phil.

 

[marc_kowal]

Your activity level will definitely play a role in your INR levels. If everything else remained the same, and the only change was your exercise routine (which would affect your metabolism rate), then that's what is causing the lower levels. As your metabolism speeds up, you process the Coumadin a quicker rate. Hope that helps.

 

[pellicle]

Phil

To add to what mark said above (which I agree with) if you get sick then the reverse will occur. This is of course the beauty of time testing. You can make sure you mimise your time "out of range". Just like a diabetic needs to check thier blood sugar levels, only they check many times a day, we only check weekly

What's your daily dose BTW?

Also, you may find this interesting. Even if you don't use it the data and calculations make it an educational read:
http://www.pharmgkb.org/download.action?filename=IWPC_dose_calculator_6-19-09.xls
From http://www.pharmgkb.org/guideline/PA166104949

 

[Protimenow]

In the weeks post-op, it is often a bit of a challenge to get the dosing right. Personally, I would be concerned about INRs below 2.0 -- especially if multiple tests were ALL that low. I don't know if the risk of clot formation is higher or lower in the 3 months post-op, but I'd prefer not to take any chances and aim towards 2.5 or higher (I' not a doctor, so you may want to consult with your cardiologist or surgeon on this), but maintaining an INR that is below 2 would be scary for me.

In your original message on this thread, you didn't indicate which type of valve you have.

As Pellicle hinted at, having a meter and regularly self-testing (until you're stable, this may be more often than once a week) is a good thing.

After all, it's YOUR life -- do you really want to leave the INR management - especially the post-op management - to someone with a smaller stake in your wellbeing?

(I did. I think most of us did. If meters were available when I had my AVR 22 years ago, and if I had known about how important weekly testing was, I would have been a lot more proactive with regular testing so that I was comfortable that I was always in range).

 

[Phil]

In the weeks post-op, it is often a bit of a challenge to get the dosing right. Personally, I would be concerned about INRs below 2.0 -- especially if multiple tests were ALL that low. I don't know if the risk of clot formation is higher or lower in the 3 months post-op, but I'd prefer not to take any chances and aim towards 2.5 or higher (I' not a doctor, so you may want to consult with your cardiologist or surgeon on this), but maintaining an INR that is below 2 would be scary for me.

In your original message on this thread, you didn't indicate which type of valve you have.

As Pellicle hinted at, having a meter and regularly self-testing (until you're stable, this may be more often than once a week) is a good thing.

After all, it's YOUR life -- do you really want to leave the INR management - especially the post-op management - to someone with a smaller stake in your wellbeing?

(I did. I think most of us did. If meters were available when I had my AVR 22 years ago, and if I had known about how important weekly testing was, I would have been a lot more proactive with regular testing so that I was comfortable that I was always in range).

Hi protimenow,

My surgeon wants my INR within the 2-3 range and for the first month I was able to maintain this. My doses over the last 5 weeks have been 3, 3.5 and occasionally 5. Yesterday (Friday) I tested at the lab and they advised taking 8 last night, 4 tonight and 4 tomorrow night and to retest on Monday. I had my aortic valve and ascending aortic root replaced and a MAZE ablation.


Phil.

 

[AgilityDog]

If you take 8, which is double your dose, you are setting yourself up for a roller coaster. You will SPIKE and then they'll drop your dose, and you'll wind up low again.
Don't do that.

Please go on line, look up an INR dosing calculator, input your dose and your INR and compare the instructions to what your lab or doctor tells you. Just GOOGLE it, if you can't find one on the stickie threads.
BTW, as you heal, as well as as you increase your exercise, your metabolism naturally improves, so it is not unlikely to have to increase your dosage the first few months after surgery.

Don't diet the dose. Eat normally, making sure you try to eat a consistent weekly intake of greenery. Don't limit it to try to stay with your dose. Dose the diet. Don't diet the dose.

 

[Protimenow]

I'm with Laurie.

They advised you to double your dose because your INR must be somewhat below 2.0. Didn't they at least tell you what your INR was?

Taking 8 tonight and 4 for the next two days isn't going to give them anything representative of a steady INR.

Ideally, you should be taking the same dose every day, which it doesn't sound like you're doing. They're want you to take a total of 16 over the next three days. The 8 is intended to bring your INR up fairly quickly -- but guidelines that I've seen call for a maximum of 1.5X your usual daily dose.

To get that 16 over 3 days, it may make sense to take two fives (if you have them) and then six (one 4 mg plus another half of a 4 mg, assuming that you have them). Of course, the goal is to get you into range and to keep you there, and the secondary goal is to get you out of a danger zone. If you haven't been tested for a week, I'd go with the 8 mg, because you may have been below 2 for as long as a week and it's not a bad idea to be just slightly aggressive, but a 6 mg should also raise your INR - but not as much). If you take 8 tonight, then test on Monday, your clinic just may start that roller coaster running because your INR WILL reflect the doubled dose.

As I think I mentioned before, strongly consider getting your own meter. Once you find the right dosage to keep you stable, weekly testing can confirm that you're still in range.

 

[gerrychuck]

Hi Phil; I really chased my INR as my activity level increased too; it was very stable in my early recovery period, then dropped steadily as I resumed more and more exercise, activity and work (and went off amiodorone, which also has a major effect on INR); took several weeks for my dosage to catch up with the activity, and I had difficulty keeping the INR above the bottom line for my target range. I was frustrated and concerned, but the pharmacists with my warfarin program assured me that this was a very normal process and not to panic. Sure enough it stabilized very nicely at a dosage of 8 mg/day. When I dip a bit under my target range (2.5-3.5) they usually have me increase my dosage by about 2 mg for ONE day, then resume my usual dose, which seems to bring things nicely back in line. The only real exception to this was this past week, when my INR spiked for unknown reasons at 4.2 - never been anywhere near that high before. For that, they recommended a one time dose of only 2 mg followed by resuming my usual 8, with a retest in about 4 days (takes that long to see effective adjustment in levels). They try to make as few deviations from the normal 8 mg as possible, as I have been overall very stable at that dose. As others have said above, weekly testing is the key. Oh, for the record, I REALLY bruise with an INR of 4.2! Definitely don't want to bang my head right now....

 

[pellicle]

If you take 8, which is double your dose, you are setting yourself up for a roller coaster. You will SPIKE and then they'll drop your dose, and you'll wind up low again.

I agree. I was on the QML warfarin management program, and those people had my dose up and down by large amounts and reqularly had me back in for testing. In retrospect their dosing was like a fight between a risk manager and a pharmacist.

When I learned more about it I ended up even arguing with a surgeon who was put in charge of me at the hospital (on one of my visits for a debridement). I discovered surgeons actually have a very narrow understanding of dosing. They afterall see patients for only a short time and under very specific circumstances.

I had an argument with the above mentioned surgeon who wanted to set me up for a seesaw (as I saw it) and I took their dose and self administered additional warfarin (which I had brought in) ... turns out that from the next reading my dosage decision was right, his was wrong.

Dose the diet. Don't diet the dose.

Yes.

If you look at the graph below you

You will see that the INR responded in a large swing for very minor warfarin changes. If you monitor your INR daily (and I have) you will observe natural swings in it even with a stable diet. I did this to myself as an experiment to learn about my own variation. I did so after reading that natural INR swings are less likely to cause clotting than dose finger related ones.

Also note the spike in the chart, thatwould have been seen as a reason to drop my dose by QML. It self corrected.

 

[Phil]

Hi All,

Thanks very much for your comments and suggestions. My gut feeling is to go with home monitoring results and online dose recommendations as opposed to the lab ones. I need to think about it a bit more as I know how important warfarin management is, and don't want to stuff it up.

Again thanks.


Phil.

 

[Protimenow]

Phil:

Self-testing is the way to go for many of us. Although I'm a bit of a fanatic about testing at the same time with multiple meters, it looks like Pellicle's daily testing reveals another area of interest in anticoagulation and response to warfarin.

In the past, when I've had an ample supply of strips, I would occasionally test more often than once weekly. I've had a few occasions where my meters reported an INR below 2.0. On some of those occasions, I took a dose of 1.5 times my normal dose. The INR spike doesn't take a long time to see - so the next day, I have tested to see if I was back in range. If I am ABOVE my range, I usually don't do anything different, and by the next week, without making any changes, I'm usually back in range.

Although I usually test once a week, on occasion (like the one already mentioned), I'll test more frequently. At times when I was almost out of strips and had no idea when I would be able to get more, I moved my testing frequency to 10 - 14 days. I'm not comfortable with tests more than a week apart.

Your dosing recommendations, based on dosing charts, are probably pretty good. I've seen some rather crazy adjustments being advised that would probably start a roller coaster effect - and these were made by 'professionals' who didn't know much about Warfarin's half-life or its effects.

It's YOUR life. It probably wouldn't hurt to learn all you can (or as much as you need to know) about warfain therapy, the latency between dosing and results, and remember not to make any large changes at any one time.

 

[Hank]

Trouble with levels - exercise theory

This topic is one of the main reasons I created valvereplacement.org. I have been home testing for about 12 years now and it has become so much a part of my life that I never really think about it much anymore.

Every person is different and the only real solution is to know your own body and how it reacts to every different factor (environment, diet, activity, and about 14,000 other things). If you are educated, you will be able to help your Dr. care for you more effectively.

There are no solutions to the warfarin dosing quandry.

My years of personal experience have instilled in me three basics that have served me well.

1 - Maintain a consistent diet (basically same levels of vitamin k containing foods every day)
2 - Bleeding seems to me to be more reversible than clotting, so I err on the side of having my INR too high.
3 - Know your Body and how it reacts to dosage changes and external INR changing factors.


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[pellicle]

Phil

Take your time. I did a year on the QML program and that gave me time to understand what was going on, build confidence in myself at being able to do this (directly post surgery is not a good time) and see the reasons why I would want to do it.

We are all just different enough to prefer different outcomes

 

[Protimenow]

Hank -- it's great to see you posting on these forums.

Great advice.

 

[Phil]

Phil

Take your time. I did a year on the QML program and that gave me time to understand what was going on, build confidence in myself at being able to do this (directly post surgery is not a good time) and see the reasons why I would want to do it.

We are all just different enough to prefer different outcomes

Hi pellicle,

This is a silly question - what is QML?


P.

 

[pellicle]

Hi pellicle,

This is a silly question - what is QML?.

There are no silly questions. I forgot you were from Vic

Queensland Medical Laboratories

Their page picture seems to sum up their target group

http://www.qml.com.au/IamaPatient/PatientSupportClinics/WarfarinCareClinic.aspx

 

[Phil]

Thanks pellicle,

Victoria yes, but I did live in Toowoomba for a couple of years in my early 20s.

First day back at work today. Am feeling very much like I don't want to do this. It will be good to see my buddies, but the work and associated pressures much less so. At least it's a phased return this week and next.

Take care.


Phil.

 

[Protimenow]

My first day back at work was a day that involved flying to San Jose, driving to a vendor or two, getting a story, then flying back. An important call home from the airport when I was on my way home was to my mother - who told me that she had Breast Cancer. What a great day back to work....

Yours can't be any worse than THAT.

 

[Phil]

True. Bad news, but I hope it's been detected early and her outcome is good. My thoughts are with her and you.

All the best.


Phil.

 

[pellicle]

First day back at work today. Am feeling very much like I don't want to do this. It will be good to see my buddies, but the work and associated pressures much less so. At least it's a phased return this week and next.

Don't push too hard. Not saying you are, as only you can know. Better to keep making small steps fwd than try to step too far and slip back.