What's Up With My INR Part II

[Nancy]

Joe's on something like 72 mg per week right now. He's on so much medication ( 14 different ones per day), I'm sure the whole mix interracts. He doesn't take any vitamins. But I do make sure he eats healthy, and that included a large variety of vegetables. I do try to keep greens to a moderate level though.

 

[Ross]

Well here we are, another week has gone by and after my 10% round down reduction, I came up with a 2.3 on 40mg per week.

Now when I was 3.8 the Card wanted me to reduce by 20% and I haggled for 10. I think we should have left it well enough alone last week. This week testing at 2.3, he wants me to continue the same dose and retest in 2 weeks in which I informed the nurse once again that I test weekly.

I can tell this is going to be fun!

I'm so tempted to add my 10% back on and not say anything, but I don't want to risk losing the priviledge. Decisions, decisions, decisions.

 

[Raverlaw]

Ross,

I self-adjusted today after the nurse said she would have the doctor call me back and I got no call. I'll tell them, but not until after my next test on Monday. I'm betting I can get closer to my range than they can.

 

[Nancy]

Make sure you have a discussion with your doctor about not getting back to you. That's really not acceptable.

 

[Ross]

I'll play it his way for one more week. If it's still low, I'm telling them what I'm going to do and not asking. We'll see how that goes over.

 

[Georgia]

BETTER WATCH OUT . . .

BETTER WATCH OUT . . .

You folks know what happened to me when I "questioned" my pcp - he told me to take a hike. And I now have a much better pcp who will negotiate and not overreact and knows how long it takes for coumadin to act.

Oddly enough, my inr has stabilized since I changed pcp's.

Anyway - be prepared to find a new doctor.

 

[Billy]

Forgive me folks.....

Forgive me folks.....

....I usually stick to the SmallTalk department these days as I don't have an artificial valve, however one of the most fascinating subjects here must be the coumadin/warfarin issue.

For those who may be new to VR, back in 1998, Myrtle my wife died ten weeks after having a St. Jude silzone valve implanted. Apart from her heart-valve condition, she was a very fit and otherwise very healthy 44 year-old.

In the course of my investigations into the circumstances surrounding her death, I became very interested in the warfarin subject and have read extensively about it. It would seem that there are many and varied opinions in every aspect of this medication. Some Doctors say 2.5 - 3.00 and some say 3.00 - 4.00. My personal opinion is that none of them know. They simply try to treat this as a trial and error exercise and as there are so many variables between individual lifestyles and metabolism, they just hope that they can keep patients in a close enough range to avoid either a nosebleed or a stroke.

The most interesting part of my investigations took place when I had an 'audience' with a Director of St. Jude Medical (Europe) about a year ago. I asked her what St. Jude's recommendation for an ideal INR reading was and she said that St. Jude was not able to make recommendations about INR readings. She said that anticoagulation was not a subject for them, it was for the Doctor or Cardiologist to decide. I suggested to her that surely as valve manufacturers they had some responsibility to research this subject and make recommendations but she was adamant that this was not the case.

I further suggested that this was like selling a new car without suggesting how much petrol to put in the tank, or how much oil to put in the engine. This information is furnished by the car manufacturer, not the dealership where it is purchased or serviced. I also explained that, from my knowledge of the subject, in many cases new cars come with a lot more after-sales service and monitoring than do St. Jude heart valves. Obviously I did not win any friends with these remarks.

It seems totally crazy to me that so much research and development goes into designing the device and yet the manufacturers are not prepared to help in respect of keeping it working efficiently.

But that's simply my opinion...........any comments?

 

[ShezaGirlie]

Skinny sisters....NOT!

Skinny sisters....NOT!

Terry -- I take 70mg weekly and I'm not skinny either...

And Farmer Crawford -- my vitamin doesn't have 'K' in it either...and I only take 5mg lisinopril in addition to warfarin. Less drugs than most folks.

Billy -- it doesn't make sense to me about the SJM Director not being aware of testing the hemodynamics of their valves...surely they do this testing????

Ross -- I would be very pleased with a 3.8 reading!

Also, I don't think there is a similarity between metabolizing fat and metabolizing warfarin. Have to ask Al on that one. We just have good livers Terry!

Where is fat metabolized anyway? Anyone know??

 

[Georgia]

Obviously my fat is NEVER metabolized!

 

[Guest]

Fat is only deposited. Well maybe secreted as in oily skin. But I agree never metabolized.

 

[Ross]

Janie I wasn't upset with my 3.8 at all. The problem occured when I called it in and they contacted the Doctor. I'm sure had I been eating normally, that 3.8 would have been reduced to 3.2 or there abouts. I like to eat my greens and the way it stands now, I might as well forget it.

 

[Billy]

The Doctor.....

The Doctor.....

Ross....I think you've proved that when it comes to your body and INR, you know more than the Doctor....

He works on theory....you work on practice....and practice makes perfect.....right.

Cheers,

 

[Raverlaw]

Fat is metabolized in the gym!

 

[Ross]

Re: The Doctor.....

Re: The Doctor.....

Ross....I think you've proved that when it comes to your body and INR, you know more than the Doctor....

He works on theory....you work on practice....and practice makes perfect.....right.

Cheers,

If only I could get him to see it that way............Perhaps he and I will go a round or two when I see him in May. Problem here is I still have 6 weeks or so of fighting with him until then.

 

[spillo]

Isi

Isi

Hello everyone,
I was reading about coumadin here, although I plan on having a bovine pericardial valve put in the aortic position in 2 weeks.
I would be interested in the ISI value of the thromboplastin used at the labs people are going to. Maybe you should be also.
The closer the ISI ( international sensitivity index ) is to 1.0 the more sensitive the inr value is to pt changes.
If your labs uses thromboplastin with an ISI of 1.5 or more that isn't so good. I think the highest I have seen is 2.5. The closer it is to 1.0 the more expensive this reagent is so many labs use thromboplastin with a high ISI value. My lab tries to buy thromboplastin that is 1.3 or lower ISI.
If your inr changes by 10% using a home meter I would think that is in the range of error for these machines so a 10% difference may be no difference at all. I am not sure of this. I have never even seen one of these. I only know other point of care, waived devices figure in a 10% error, up or down.
In other words if you do 3 tests in a row and you get inr's of 3.0 then 2.85 then 3.15 that would be 10% error.
On a clinical machine the pt results must be within 0.5 seconds in duplicate testing for us to be able to turn out a result. The INR is a calculation so labs work with the pt results to check accuracy of their methods.
Also, I never read anyone mentioning their pt value, only their inr. Why is that ? I always thought that after a certain high inr value ( 8 or so ??? ) the inr is of little use and you go by the pt value.
Even though I could get free pt/inr's all day long I don't want the hassle and confusion I see in some of these posts. To each his own though. I know most of you swear by mechanical valves and I think that is wonderful. I am happy to see everyone doing well on whatever they choose. The mechanical is just not for me.
Best to everyone,
spillo

 

[Ross]

God only knows the ISI value at the lab where I went. I know the ISI is 1.0 for the HemoSense INRatio monitor and ITC Protime, Coaguchek is soon to follow but is still at 2.0.

I truly think that the lab I went to used different reagents everytime I tested there. I always had wild swings that I'm not having home testing.

As far as only quoting our INR and not the actual PT, it's only the INR are Doctors are concerned with, not the actual seconds it takes to clot.

Spillo I'm not trying to change your mind any on your valve choice, but once you've had this surgery, you may rethink that position. Sometimes what we want and what we get are completely different also.

 

[Guest]

There are few adverse events that occur with INRs below 5.0 and even then usually nothing serious happens below 8.0. So there is no need to measure the INR down to two decimal points. The ISI only becomes important the further away from the desired range that the INR goes.

I have done over 20,000 patient visits with a CoaguChek and found that reporting the PT to physicians only serves to confuse the issue. The PT varies with the ISI and many have old numbers memorized and if you give them the PT they don't know whether to go by that or the INR.

You are correct in technical terms, but in practice the technical aspects far exceed the degree of accuracy needed to keep people from clotting or bleeding.

The guidelines are generalizations, not absolute mandates. For instance for mechanical valves the guidelines say INRs between 2.5 and 3.5. However, this was set by a committee. We do not know that the actual data said 2.4 to 4.3 but some influential member of the committee thought that this was to hard to remember so it was set at 2.5 to 3.5.

People with INRs of 2.39 do not immediately clot and people with INRs 0f 2.51 do not have blood spurting. Besides the number, we have to take individual situations into account too.

The people who are most dissatisfied with warfarin are those who try to live in strict accordance with the guidelines.

 

[spillo]

Hi Al,
We do not report inr's with 2 decimal points, we round them off. It is not a measurement however, just a calculation so I think some lab techs. may report whatever their computer spits out.
I only used 2 decimals to make the point of percent error.
A few things that do change results are the percent of citrate used in the blue top. Most labs have switched to 3.2 % but some use 3.8. There is a difference if the lab uses these interchangabley, which they should not. There have been studies as far as changes in results when the tube is not filled correctly, or totally. Also how the tube is stored until testing makes a difference. Finally, a tramatic stick can get more than normal tissue juices in the tube which could change results slightly.
I would advise people to go to a lab that uses a low ISI thromboplastin, performs the test within an hour or so, uses 3.2 citrate ( more sensitive ) and has good phlebotomists. Then if you can always go on the same weekday at about the same time of day you will have a better chance of always having the same tech. run your specimen.
The fewer the variables the better !
Good luck everyone !
spillo

 

[Blanche]

Spillo:
You've provided interesting information on labs, which I will put to good use very soon. I can't disagree with what you say, but in my part of the world, it just does not work that way. In our case, the doctor or the phlepotomist at the doctor's office draws the blood. It then sits in the office until it is picked up by messenger, who continues making pick-ups for heaven only knows how long. The sample is then taken to one of three locations, to sit and wait for another messenger to deliver it to a central location to be tested. Sometimes the doctor will use a hospital lab, which is about 22 miles away. Again, a messenger picks up the sample, continues to pick up other samples at other places, and finally drops off the samples. They are then tested at the hospital lab, in the evening, when the lab work for the hospital has been done. In our area, one lab has a virtual monopoly because they have lab offices near the hospitals and in most of the large medical complexes. What people don't know is that most of the lab work is sent to the central office for processing. Given the volume of testing that they are doing at the central location, the batches of reagents are changing frequently....and each new batch is likely to have a different ISI.

The doctors think that the lab test yields the most accurate p/t. We home test, but our doctor requires that a lab test, for QA purposes, be done monthly. I am currently in the process of attempting to get his permission to to all tests on our ProTime monitor. His last response, today, was "Sorry, we need that monthly lab test for QA." QA my foot!

Many thanks. I will use some of your suggestions in my rebuttal.

Kind regards,

Blanche

 

[Guest]

This is why people flock to our service that uses a CoaguChek. The results are there within 2 minutes. I also use a fax built into my compurter. I type up the notes for the visit while ther person is sitting at my desk. They are faxed to the doctor before the person can walk out the door of the office.

My three main points for outpatients are:
1. Increase the dose if the INR is more than 0.2 units low.
2. Rarely hold a dose if the INR is under 5.0.
3. Don't use vitamin K if ther person is not bleeding

My complication rate:
A minor bleed every 18 patient months.
A major bleed every 33 patient years
A clotting event every 100 patient years.

I'll challenge anyone using any other method to show better results.