Up and down INR!?

[EMJEF]

Hi everyone,

hope you’re all well. I’m in a bit of a quandry. I tested my INR on Tuesday and it was 3.7 which is obviously high but not surprising since being off diet for the holidays and maybe a few too many wines over the weekend. I adjusted my dose and retested on Thursday and it had dropped to 1.7 which was a bit concerning. I then reverted back to normal dose - basically 9 and 10mg alternate days. I have retested again today (Saturday) and it’s dropped to 1.4. I had been stable at 2.3-2.7 for quite a while so am obviously a little concerned about this. I don’t drink enough water and it has been very warm this week. Anyone know if this may effect my levels? Was thinking of taking an increased dose tonight and tomorrow to hopefully jump it back into range and then call my pharmacist on Monday morning.

Any advice greatly appreciated

 

[user 16827]

Hi, the obvious question to me is how much did you drop the dose by ? if 9 / 10 is your normal ?
just one day adjustment or more ?

i see you are in the aortic position, at 3.7 i wouldn't worry over that , as you know at 1.4 you are now out of therapeutic range .
any dose change today will take 2 to 3 days to reflect in your INR.

i would up the dose yes, but please dont worry as a few days out of range will not cause you to clot.

@pellicle will chime in soon

 

[pellicle]

Hi

I tested my INR on Tuesday and it was 3.7 which is obviously high but not surprising since being off diet for the holidays and maybe a few too many wines over the weekend. I adjusted my dose and retested on Thursday and it had dropped to 1.7 which was a bit concerning.

what did you adjust your dose to?

I then reverted back to normal dose - basically 9 and 10mg alternate days. I have retested again today (Saturday) and it’s dropped to 1.4. I had been stable at 2.3-2.7 for quite a while so am obviously a little concerned about this.

I don’t drink enough water and it has been very warm this week. Anyone know if this may effect my levels?

not in any significant way ...

Was thinking of taking an increased dose tonight and tomorrow to hopefully jump it back into range and then call my pharmacist on Monday morning.

it would be very helpful if you'd discuss specifics and not use qualitative language.

As @leadville points out it takes time for things to happen, drops are usually faster than resumptions (theres a discussion in that). I also agree that lower INR for a few days isn't a worry given that your situation is Aortic position mechanical (with no A-Fib or other stroke history).

Probably you drank or ate something (you weren't drinking grapefruit juice were you?) which caused a transient elevation in INR, perhaps it was some alcohol (doesn't really change me but I have seen enough cases where it does), perhaps it was something else. I agree I'd probably have reacted to seeing 3.7 too

The thing about making adjustments is you need to have a plan and understand what's happened in the past and why and from that decide what you're doing.

However I agree with your plan to take an increased dose ... what do you plan? 1mg or 10mg?

To reiterate can you be specific about what you doses were between Tuesday and now?

PS when was your last INR test, what was the result.

 

[pellicle]

...

I think you had it covered.

10pm here, so off to bed.

 

[EMJEF]

Hi, the obvious question to me is how much did you drop the dose by ? if 9 / 10 is your normal ?
just one day adjustment or more ?

i see you are in the aortic position, at 3.7 i wouldn't worry over that , as you know at 1.4 you are now out of therapeutic range .
any dose change today will take 2 to 3 days to reflect in your INR.

i would up the dose yes, but please dont worry as a few days out of range will not cause you to clot.

@pellicle will chime in soon

Thanks for getting in touch.
I probably overreacted and dropped down to 5mg for two days (Tues and Weds) Then have gone back to normal dose. Will take 10mg tonight and tomorrow (normally 9mg for both weekend nights) and hopefully that’ll boost it back into range.

 

[user 16827]

@EMJEF you are very welcome, yes ~ 50% reduction for 2 days is a huge adjustment based on 3.7

effectively ~10mg down over the week ( although some hate the weekly term ) : )
so around a 15% week dose drop.

i much prefer small dose adjustments as this helps to negate the roller coaster issue that you
now have.

the half life of warfarin stays in your system so you are actually dosed more than the 9/10 you take daily.

your roller coaster was heading on a downward trajectory with the dose drop + the drop in half life that's why your 1.7 continued to 1.4.

you should get back to a therapeutic range ~2 soon then back to target.

don't worry you will not clot, just consider smaller dose adjustments in future

Please update us once you are back in range ( at target )

give yourself 48 to 72hr to see any real change
good luck

 

[Amy]

Just curious - when you all have a low, out of range INR like this.... do you try not to take your daily vitamin k, or maybe skip your usual salad or avocado etc? (In fear/anxiety of setting off a tia) Or do you keep your diet and supplements the same, so that you know when your inr increases it was all due to the warfarin increase?

I tend to want to do the former, then regret it when I check my INR, especially when I’m then *just* in range.

Just wondering what you guys *actually* do, though I think I know what the ‘correct’ answer is.

 

[user 16827]

Personally Amy if I'm ever low I dose the diet.
The less variables for me now the better.

A few years ago i did try that but i find a consistent diet is the better way now ( for me )
and i just alter my dose

 

[EMJEF]

I usually just alter the dose. This week my diet has been all over the place as been off work and enjoyed time with the family so few different things going on. However, on the whole think it’s better to just alter dose so I know it’s warfarin that’s effecting change not a range of things. Easier to keep a track then.

 

[pellicle]

Hi

Just curious - when you all have a low, out of range INR like this.... do you try not to take your daily vitamin k, or maybe skip your usual salad or avocado etc? (In fear/anxiety of setting off a tia) Or do you keep your diet and supplements the same, so that you know when your inr increases it was all due to the warfarin increase?

so here's what I do (and why)

I never adjust my diet, because (feeling like a stuck record here) it makes essentially zero difference. Any significant difference people (think they) find is usually a coincidence. Very few people here keep weekly readings and even fewer go about deliberately testing in a rigorous way. They might notice something and then just mentally note that lettuce made a difference. The reality is that you'll need to eat so much of that stuff you'd need to be forced to do it (I mean about a kilogram of lettuce (or a few whole lettuces) to see any dent in INR.

You can never be sure with any level of precision exactly what caused what ... its been said here many times because its true. Your body is a complex system even with some imagination that you're keeping everything the same. Some people are rock solid, some people have variations. Seeking to explain them is like seeking to explain why the wind came up (and even the weather bureau fails at that with any accuracy).

I don't "guess" a number I have a system which allows me to see on a table (like a small version of a lookup table used once in maths for log or sine/cos/tan) and based on my readings and history make a decision. My experience however is 90% of people just aren't that interested in maintaining that (until there is an issue to deal with, then they're full of anxiety and reaching out all over the place for help).


Best Wishes

 

[pellicle]

a recent point of relevance
https://www.valvereplacement.org/threads/my-self-management-results-for-2020.887821/post-902559
where I wrote:

... from this site:​

​

Warfarin reversal: consensus guidelines, on behalf of the Australasian Society of Thrombosis and Haemostasis​

Warfarin reversal: consensus guidelines, on behalf of the Australasian Society of Thrombosis and Haemostasis​

www.mja.com.au​

​

we find the following guidance (bold mine for emphasis):​

​

The amount of vitamin K in the diet partly determines the sensitivity to warfarin. This is important to consider in situations when diet changes, such as during illness, travel, fad diets, hospitalisation and postoperatively. Dark green vegetables such as spinach and broccoli are typically high in vitamin K. However, it takes a very large daily intake of “greens” to influence the INR. Rather than restricting vegetable intake, it is better to recommend a balanced and consistent diet​

​

The optimal IV dose of vitamin K1 for partial reversal of over-anticoagulation with warfarin is 0.5–1.0 mg. If correction of the INR (rather than just return to the usual therapeutic range) is desired, larger doses of vitamin K1 are needed (see Box 3). The INR can usually be normalised within 24 hours with an IV dose of 5–10 mg of vitamin K1.​

​

The point about dark green is significant and can be found by searching foods and making the observation yourself.​

remember that mg means millligrams > so one thousand = 1g

it takes 1 thousand micrograms to equal 1 milligram

so 1000mcg = 1 milli gram

even the foods highest in vitamin k have micrograms per serving

another example:
https://www.valvereplacement.org/threads/warfarin-and-cheese.877760/post-877776

 

[EMJEF]

Thought I’d update you all on the saga of my INR. So I increased my dose by 1mg for Saturday and Sunday and since then have taken my normal amount. Tested INR on Monday morning and it had increased to 1.7 from 1.4. Have just now taken this morning (Weds) and it’s back in range (2.3). Thanks for all of the advice on here.

 

[pekster11]

so, i've been getting tested weekly for INR by the phlebotomist
last test (on Monday) gave an INR reading of 2.8
2mg a day has kept me in range for over a month now
thought i was nice and stable

Just used my coaguchek INRange meter for the first time since my operation and got, 4.6 !!!!
Retested and got 4.7
Used a quality control check and got 1.9 (which is the value it's supposed to be)

Bit worried now, got to admit

 

[user 16827]

Hey @pekster11 firstly dont worry thats the main thing.

so how long was in between the 4.6 and the 4.7 ? it should be the same reading if we are talking minutes not hours.
even at 4.7 if you look at pellicle's graph you are only at the outer edge.

forgive me if i state the obvious but with it being new to you, are you getting the blood onto the strip within the 15 seconds.. ( that will coagulate i know just checking your method )

if the 4.7 is correct it will require a dosing adjustment as no doubt you know


any major dietary changes this week ? large quantity of grapefruit juice, cranberry ?

 

[pellicle]

Hi

Retested and got 4.7
Used a quality control check and got 1.9 (which is the value it's supposed to be)

Bit worried now, got to admit

I'm a bit confused here, but first let me say that a high INR does not cause a bleed, that you know you have a high INR means you can be careful and not combine that with something which does (like falling down the stairs).

Heaps of people find themselves at much higher INR coming to no harm.

This is why we test, to reveal what we can't see.

So, is your INR >4 or about 2?

 

[pekster11]

Hey @pekster11 firstly dont worry thats the main thing.

so how long was in between the 4.6 and the 4.7 ? it should be the same reading if we are talking minutes not hours.
even at 4.7 if you look at pellicle's graph you are only at the outer edge.

forgive me if i state the obvious but with it being new to you, are you getting the blood onto the strip within the 15 seconds.. ( that will coagulate i know just checking your method )

if the 4.7 is correct it will require a dosing adjustment as no doubt you know


any major dietary changes this week ? large quantity of grapefruit juice, cranberry ?

Had a few glasses a day of dilute to drink pink grapefruit. Maybe that's the cause?

 

[user 16827]

Had a few glasses a day of dilute to drink pink grapefruit. Maybe that's the cause?

i would put money on it yes, the dreaded grapefruit has caught many of us out

are you comfortable to dose yourself and check again in 3 to 4 days ?

 

[pekster11]

Hi


I'm a bit confused here, but first let email say that a high ONE does not cause a bleed, that you know you have a high INR means you can be careful and not combine that with something which does (like falling down the stairs).

Heaps of people find themselves at much higher INR coming to no harm.

This is why we test, to reveal what we can't see.

So, is your INR >4 or about 2?

My Inr is above 4 according to the coaguchek meter.
The Roche control sample I tested gave the result is was supposed to 1.9. Makes me think my blood inr was correct.

I'm still going to take my daily warfarin dose of 2mg daily, and cut out the dilute to drink pink grapefruit juice. Home test my inr again in a couple of days and get my Inr clinic to test me during the week. That's my plan

 

[pekster11]

i would put money on it yes, the dreaded grapefruit has caught many of us out

are you comfortable to dose yourself and check again in 3 to 4 days ?

Yes. I plan to do that in a few days. Honestly can't believe a few glasses a day of the dilute to drink(not pure stuff) has increased my Inr so much tbh

 

[pekster11]

Do you think I should take 1mg of warfarin today rather than my scheduled dose of 2mg?