Watch it!!!

[Protimenow]

There are all kinds of things that can cause changes in our INRs. Mine has been pretty consistent for a few months.

I humor my anticoagulation clinic by getting blood draws, but do my own monitoring.

On Monday, I switched from a multivitamin that has just a trace of Vitamin K in it to one that, apparently, has NO vitamin K. (I read a comment on the Life Extension site that said that there was no Vitamin K in the 'Mix' vitamins. BTW - those vitamins seem to be better for me than the 'Mega Men' that I was taking).

I figured that, without that little bit of K that I was getting from my old vitamins, my INR may increase a bit. Although I preach that testing should be done weekly, it's been 11 days since I last tested. My INR on my Coag-Sense was 3.3 -- within my desired range, but perhaps a bit lower than what a lab test will show. I did a follow-up test with a CoaguChek XS Plus and got a 4.4. The actual INR is probably somewhere in between -- maybe 3.7 or so.

Although this doesn't worry me, and I can add some greens and will take a half dose of warfarin tonight, my crazy, misguided Anticoagulation clinic will freak if the lab showed 3.7. (For some crazy reason, they want my INR to be between 2.0 and 3.0). I won't have my blood drawn until I know that the nutso clinic will be happy with the result.

My point here is that, even with changes as subtle as switching vitamins, our INRs could make changes of a few decimal points. It is always a good idea to test INR after major changes (although, to be accurate, unless the INR spikes into dangerously high range, having an INR that's too close to 1.0 can usually be made before there are any lasting effects).

I've got to kick myself in the butt -- if my leg will reach -- and make myself follow my own advice to a) test weekly and b) test again if I do something or make a change (like dropping a vitamin that had K and replacing it with one that doesn't) that might change my INR.

(FWIW -- those Monthly tests at a clinic or lab won't tell you a THING about what happens between tests. More regular self-testing is perhaps the ONLY way to be sure that our INRs stay in range -- even if our INR is 'stable.')

 

[Marty]

Hi, a very interesting post. However once you find your sweet spot monthly testing is OK. In my experience patients self testing are more likely to adhere to this regimen and it is quite safe. Now if there has been a medication change or illness...test. If the patient is then out of range test weekly using the 10% rule till new sweet spot established. Warm regards Marty

 

[Protimenow]

That's the problem Marty -- I don't think that there IS a sweet spot. Yes, I manage to keep my INR in range almost all the time that I'm testing, but there ARE times when it's out of range -- and we don't always know that we've done anything to put us there.

If I was a medical practitioner, I'd be concerned that one or more of the patients that I monitor monthly (or bi-monthly) does something to put them out of range for an extended period. Perhaps the patient isn't taking the right dose, perhaps the patient switches vitamins or diet, perhaps the patient forgets a dose then doubles up the next day, or perhaps the patient does EVERYTHING right, but STILL gets out of range. These things happen -- and if the person has a stroke or dangerous bleed, you can bet that the first person to get the blame is the health care practitioner who is comfortable with monthly testing.

(As a self-tester since 2009, I had complete reliance on a meter that gave me readings that were higher than the lab readings -- and as a result, I had a TIA. In my not too distant past, I thought like a lot of others and believed that, having been in range for some time, I could go without testing as long as my dose didn't change. I developed a 'wart' on my face that went away when I upped my dose. That 'wart' may have been an area where the clots pooled, protecting me from a stroke. I don't know. I probably never will. But I will NOT be comfortable with monthly testing - even though this would probably always show that I'm in range - because there are times when I might, for whatever reason, be dangerously out of range.)

I would prefer to be able to adjust my dosage in case SOMETHING (who knows what?) should take me out of range -- and to be able to make those changes before I've been out of range for more than a few days.

Although it may be easy to get complacent about a 'stable' INR and to believe that monthly tests are appropriate, I don't agree. There's the possibility that the INR could change BETWEEN monthly testing, and you'll never know until you've had a stroke or a major bleeding event.

Regards to you, too, Marty. But I respectfully disagree.

 

[Marty]

HI protime, your posts are always well received. I agree with your right to dis agree. Respectfully Marty

 

[Protimenow]

Thanks, Marty.

To me, the cost, both in terms of physical issues and in terms of dollar costs for treatment make a stroke a LOT more expensive than the fifteen dollars or so (3 tests, one each week between monthly tests), that weekly self-testing costs. To me, it just seems more sensible - whether or not a person is in his or her sweet spot - to test more frequently so that adjustments can be made if something crazy happens to a person's INR between monthly tests.

But, of course, we're all in control of our own INRs (whether that 'control' means going to a lab for a monthly draw, or self-testing monthly, or even self-testing more frequently), and, by extension, of our lives, so the question of how frequently to test is ultimately one that we are ultimately responsible for. (And, as I said in an earlier post, when I was unable to afford lab tests, and when meters and testing weren't affordable, I went for a long time without testing -- and was damned lucky that I didn't have serious negative results -- this was MY decision. I don't ever expect to let my test intervals exceed two weeks. With meters and supplies being relatively affordable, I personally don't see any good reason to test once a month.)

I know that I won't convince you to modify your views. That's fine. I just hope that others who are trying to decide how often to test should GET THEIR OWN METERS and DO THEIR OWN TESTING so that they can reduce their risk of events related to being out of range.

(FWIW -- since I started this post and saw that my INR was high -- especially on my CoaguChek XS Pro, I've reduced my dose from 7.5 mg a day to 6 mg a day/7.5 mg the next day (13.5 for two days, instead of 15), and am about to retest (after three days) to see if my INR is back in range. I wanted to give it three days until the effect of the lower dose became detectable. Also - if I can find a vitamin with the 80mcg of Vitamin K that was in my last vitamin, I may just add this to my regimen and return to 7.5 a day, testing, of course, to make sure that I'm still in range).

 

[pellicle]

Hi

I just read this today:Practical tips for warfarin dosing and monitoring

In addition to their anticoagulant effect, the vitamin K
antagonists inhibit carboxylation of the regulatory anticoagulant
proteins C and S and therefore have the potential
to exert a procoagulant effect.
In the presence of calcium ions, carboxylation causes a
conformational change in coagulation proteins that
promotes binding to cofactors on phospholipid surfaces.

I've just had an unexplained spike in my INR, up to 3.2 from 2.0 which was as a responce to a gradual winding down of INR over the last 3 weeks. I'm now wondering if the suppression of my INR (which BTW had been stable for months before this) was related to me taking some Vitamin C which I now read on the bottle to be calcium ascorbate.

hmmm

 

[Protimenow]

So, in other words, even if your INR is in its 'sweet spot', there can be unexpected things that can cause the INR to change. You wouldn't have known about your 'unexplained spike' if you had been testing monthly. It may not be possible for us to really know WHAT changes, activities, medications, etc. could be changing our INRs.

The possibility of a person's INR changing unexpectedly is a major reason why I urge weekly testing (or, 8 or 10 days maximum between tests). We really just don't know....

 

[Superman]

I don't mind testing regular, but I find my coumadin clinic obnoxious to no end. I disagree with their dosing change recommendations and have long since given up trying to correct them. I just say, "okay, sounds good" to get off the phone, then do what I think is correct.

I was at 2.4 this week and they wanted to bump me 2mg weekly from what they think I am taking; which would be 4 mg over what I'm actually taking. (I used to correct them, but found that at the next weeks call, their records never get updated to the accurate dosing anyway). I told them I had additional greens this weekend outside my normal diet, and I'm 0.1 below therapeutic range. My reaction, since I've been as high as 3.3 on my current dose, is to leave things as they are. So now they think I'm taking 6 mg 4x weekly and 5 mg 3x weekly. In reality, I'm taking 5 mg daily and have been for months.

I wish I could fire them, but insurance pays for the strips so long as I'm monitored by the clinic. I've been dosing warfarin longer than any of them and know how I respond to changes. I really wish they'd listen to me and keep accurate records.

/rant

As far as the OP - cranberry juice causes my INR to spike. Big time. Don't know why, and it doesn't happen to everyone, but that's how I respond.

 

[Protimenow]

The clinics - and probably many doctor's offices that can do testing - seem to not really be able to 'get it right.' If they're happy with monthly testing, it doesn't seem to me that they really know what they're doing. I've been told to take 1/2 dose ONE TIME EACH WEEK, and this is supposed to modify my INR for the ENTIRE week. I've had my range modified, even though they know that I self-test, and don't care if my meter may always give me results that are higher than the labs. Plus, of course, they don't trust me (or any other patient) to be able to self-test or self-manage.

I get my blood drawn monthly -- primarily just to check the results against a meter. I manage my own dosing. I've been doing it for years.

Once I was able to determine - by comparing my meters to the lab results - which meter I trust (or, conversely, how much error was in the meters so that I can adjust them to come close to the lab results), I was able to more accurately manage my INR. (A couple years ago, I had blind faith in the accuracy of a particular meter -- a 2.0 on that meter was actually more like a 1.7 -- and I had a TIA as a result of this blind trust. I won't let that happen again).

I urge all of us who are on warfarin (and who are able to run a successful self-test) to get a meter (my current meter of choice is a Coag-Sense -- not as well known as the others, but giving results that may be slightly lower, or matching the lab results. I'd much rather have a meter that willl tell me that my INR is 2.0 when the lab says 2.4 than have one that says my INR is 2.0 when the lab says 1.6 or 1.7).

Back to the point at the start of this thread -- you don't always know WHAT or WHEN something will change your INR. Unless you test weekly, a drop (or spike) in your INR could put you at risk.

 

[Jamey T]

I should probably start a new thread on this, but I have kept every INR test result from the first test after my surgery. My clinic is also one that seems to think everyones range should be 2.0 to 3.0. I am 2.5 to 3.5 on my surgeons recommendation. I do monthly blood tests to humor my clinic, but test at home with the blessing of my doctor. He gave me a perscription for a meter, but insurance turned me down, so I bought an Inratio 2 out of pocket. Anyway, I had a test one time that was 3.6, and they panicked and wanted me to skip a dose that day. I told them of my range, and I was told I didn't understand how serious this was. I also told them that my INR goes up hard and slow, but drops like a rock easily. I also have a hard time to get them to tell me the results of my tests, I almost always have to ask.

Regarding the testing results, my meter is usually closer than the Inratio vs lab estimates that were posted on here about a year ago, I saved it so I could compare. But that being said, they are always higher than my blood draws. It is good to compare the results to my meter, and gives me some confidence in my meter. I know thanks to Protimenow that if I am testing at 2.5, I need to be nervous. I also compare my last four remaining test strips to my new lot of test strips, so I know how differently they will read. I always buy lots of 48, and I also include at least one lab test and a test from each lot of test strips. It isn't scientific, but it gives me a level of confidence.

Just my opinion, but with information gained thanks to these forums.

 

[Protimenow]

It seems to me like you're doing it all correctly. From logging your values to not completely trusting your clinic, and to (probably) managing your dosages and not making any rapid knee-jerk changes like the one your 'clinic' told you to do, I don't see anything that I disagree with.

I don't see a 3.6 as being all that serious -- a 4 or 5 or higher may be cause for more concern, but I would much rather have a 3.6 on an InRatio than a 2.5 on the same meter.

It looks to me like you're doing just fine....

 

[Superman]

bump me 2mg weekly from what they think I am taking; which would be 4 mg over what I'm actually taking. (I used to correct them, but found that at the next weeks call, their records never get updated to the accurate dosing anyway). I told them I had additional greens this weekend outside my normal diet, and I'm 0.1 below therapeutic range. My reaction, since I've been as high as 3.3 on my current dose, is to leave things as they are. So now they think I'm taking 6 mg 4x weekly and 5 mg 3x weekly. In reality, I'm taking 5 mg daily and have been for months.

Update. Made no changes, still taking 5 mg daily, and was back in range today.

 

[Ola Thoresen]

I have had a few "incidents" where my INR has been way too high. Around 4.5 once or twice. Every time I have kept my schedule and not changed the dose, and every time I have checked my INR again a few days later and have been back in range (2-3).
These things happen. Something you ate, something you drank, something you did caused it, and the body behaved perfectly normal. Only if I am higher or lower than I feel comfortable with for several consecutive readings over a period of time, I will change my dose (slightly).