Upper or lower range..?

[realkarl]

On my most recent INR test, I barely fell out of range (2-3) with 1.9. When I called the clinic they wanted to adjust me to the upper part of my range saying this was preferable. With my On-X valve I tend to disagree. With On-X's clinical trial it is likely the adjusted range for On-X aortic valves can be 1.5-2.0 already next year (see quoted e-mail from On-X nurse below).

My measurements so far have been:

8/3/2009	2.00
8/6/2009	2.20
8/12/2009	1.70
8/17/2009	1.90
8/24/2009	2.10
9/1/2009	2.20
9/15/2009	2.10
10/8/2009	1.90

I have only 2.5mg tablets, and I am taking 1.5 * 2.5 mg = 3.75 every day except Tuesday, when I take 2.0 * 2.5 mg = 5 mg, totaling 27.5 mg / week.
Now they want me to up this to 3.75mg*4 + 5mg*3 = 30 mg / week with a new check in two weeks.

I tried the online calculator, setting current INR to 1.5-1.99 with a target range 2-3. The result was 28.88 mg - 30.25 mg, so my coumadin clinic's suggestion is in the upper range of the calc. suggestion.

I would prefer to stay in the lower range 2-2.5 and up my dose to 3.75mg*5+5mg*2 = 28.75 mg. I guess it's not a big difference, but this being my first adjustment, I wanted to ask the shared experience in this forum if this seems reasonable? There is already a downward trend in my INR numbers due to increased activity, which I expect to continue, so perhaps I best follow the clinic's suggestion. Even that might not get me above 2.5.

I am looking forward to getting started with weekly home INR tests, but have to wait until 3 months after my surgery (insurance rule).

From On-X:
The study is SCHEDULED to complete in 2015. However, the group high risk aortic valves has almost completed enrollment. We expect a result for that group sometime next year. If the test group has the same complication rate as the control group, the FDA may allow us to recommend these patients (most aortic valve patients) to have an INR range of 1.5 to 2.0, lower than the current recommended ranges of 2.0 to 3.0 for most mechanical aortic valve prostheses. This will be a big advantage for On-X aortic valve patients because the bleeding rates are much lower when the INR is this low.

 

[Bina]

I like some wiggle room and never go below 2.5
Am happiest around 3.2 where I can eat what I like.

 

[AgilityDog]

I'd vote with the clinic's recommendation. It's 10%, or less, increase. If the Onyx valve doesn't protect you at the lower range, you're risking a stroke. I'm not willing to be that guinea pig. Are you?

Besides, if you are becoming more active as you heal, your INR will drop, and you are already seeing a downward trend.

 

[ALCapshaw2]

I'd vote with the clinic's recommendation. It's 10%, or less, increase. If the Onyx valve doesn't protect you at the lower range, you're risking a stroke. I'm not willing to be that guinea pig. Are you?

Besides, if you are becoming more active as you heal, your INR will drop, and you are already seeing a downward trend.

I concur with the above statements.

As you become more active, your INR will drop until / unless your dose is increased. Being a little on the high side gives you some protection against Stroke.

I don't recall anyone having any Bleeding Incidents even with an INR up to 5.0.

Most of our Home Testers feel comfortable between 2.0 and 4.0 with only minor adjustments to 'tweek' back into their recommended range.

One of our famous sayings is:

"It's Easier to Replace Blood Cells than to Replace Brain Cells."

That is why many of our members prefer to be on the high side of their range.

'AL Capshaw'

 

[dick0236]

One of our famous sayings is:

"It's Easier to Replace Blood Cells than to Replace Brain Cells."

That is why many of our members prefer to be on the high side of their range.

Amen to this saying. You have quite a bit of wiggle room at the top end of an INR range.....not so at the low end, especially under 2. I am much more comfortable with my INR being at the upper end of my range, 2.5-3.5.

 

[realkarl]

Thanks for all the good advice. I will increase my dose just as the clinic suggested to get well back into my range (2-3).

I guess the reason I am overly worried about a high INR level is that I have had 3-4 episodes of bad nosebleeds in the past that were hard to stop, and now that I am on Coumadin, I am reminded of the anxiety I felt during those episodes. I plan to see an ENT specialist for advice on whether something can be done to fix the thin skin and exposed veins in one nostril.

It is indeed easier to replace blood cells than brain cells.

 

[Philip B]

Nose Bleeds

Nose Bleeds

Experiences undoubtedly vary, but I've had rather lengthy nose bleeds regardless of whether I'm on the high end or low end of my range. I usually test immediately when I get a nose bleed just to see if I'm in range or too high. My last one ran for four hours and required an ER visit; I was in the low end of my range at 2.6 when I got it. After being hit by a car in June, I had a nose bleed that lasted three hours; my INR at the time was 3.2.

I also notice fluctuation when I'm in range. For me it really depends upon how my activity level impacts my metabolic rate. You may notice the same as your activity level increases.

-Philip

 

[COLLEEN S]

You are not on a very high dose. Are you comfortable with that? Everyone is different, but that is why there are "standards" such as the 2.5-3.5 rule. I prefer to be on the higher side also due to "easier to replace blood cells than brain cells."

 

[realkarl]

Colleen: The amount of Coumadin is not really important. The resulting range is what matters. As you say, everyone is different. My current recommended standard range is 2-3, but may become 1.5-2 next year. I have increased my dosage as recommended and we shall see in a couple of weeks what the result is. I should end up being comfortably in the upper area of my current range (above 2.5).
-Karl.

 

[Maryka]

Karl and Colleen: Same doctor, different INR range?

Karl and Colleen: Same doctor, different INR range?

Hi RealKarl and Colleen!

I just had a wisdom tooth pulled because trying to fill it again revealed it was rotten in the middle of the tooth. It was spur of the moment, so no change of Warfarin was done. I seem to be surviving just fine so far. (Luckily I disobeyed my dentist before going in for the filling by pre-medicating with my antibiotic.)

RealKarl, you have the same recommendations for your INR as I do (2-3). BUT I used the same surgeon and physician's assistant as Colleen. What makes the difference? The only difference I can see is that I am strictly required to take one baby aspirin a day.

 

[realkarl]

Maryka: I also take a baby aspirin a day.. From what I have read, they generally recommend 2-3 for mechanical aortic valves and 2.5-3.5 for mechanical mitral valves (or both).

Btw: My 2 week test result came in at 1.9 again (even after the 9% dosage increase). I guess I just keep getting stronger and exercise harder.. I am increasing another 8% to 32.5 mg/week, and the paperwork process to get home testing equipment is started

 

[catwoman]

Maryka: I also take a baby aspirin a day.. From what I have read, they generally recommend 2-3 for mechanical aortic valves and 2.5-3.5 for mechanical mitral valves (or both).

Btw: My 2 week test result came in at 1.9 again (even after the 9% dosage increase). I guess I just keep getting stronger and exercise harder.. I am increasing another 8% to 32.5 mg/week, and the paperwork process to get home testing equipment is started

Why the 9% and 8% dosage increases? Sounds like you really need 10-15%. If you're exercising more, you will no doubt be needing a dosage increase closer to 15% to account for that and your being under 2.0. I'd be shooting for 2.5 -- midrange.

 

[realkarl]

9% and 8% were the result of adding 2 more days of 5mg each time (3.75 mg the other days), 27.5 -> 30 -> 32.5 mg, as per the clinic's recommendation. Maybe I will do 6 days * 5mg instead of the recommended 5 days. That's 33.75mg (12.5% increase). There is probably also a time when my activity will not keep increasing as much. It's getting cold and rainy now, with less chance of outdoor activities.

 

[Bina]

I would be uncomfortable with an INR of 1.9 continuing this week and would also increase at least 10%

 

[COLLEEN S]

i would also

 

[realkarl]

I have faith on my On-X valve's ability to reduce turbulence and the chance of clotting, and that 1.5 - 2.0 will become the new recommendation. The study has not found any complications so far. Until then though I will definitely aim for 2.5. So I have increased the dose 12.5%. That should bring me well into my current range.