Warfarin INR - too high but infrequent monitoring

Hi Folk,

I'm just getting a little concerned that my local Anticoagulation Clinic is understaffed, under enormous pressure and is perhaps operating a policy which is not very safe.

I started Warfarin 10 weeks ago - and there was a three week break (while I had flu or something), but I have been on it consistently for 6 weeks. The target INR is 2-3. The clinic started monitoring me weekly, then this went up to every nine days and now I don't get seen for another 14 days.

Firstly INR was 1 or 1.3 or 1.6. Then after quite a gap it was 4.2. Yesterday it was 3.4. So although going in the right direction - it has never been measured in the target range. TTR (time in the target range) is er...0%.

I looked up the NICE guidelines for oral warfarin:

cks.nice.org.uk/anticoagula...

Generally, the INR should be measured:

Daily, or on alternate days, until it is within the therapeutic range (usually between 2.0 and 3.0, ideally 2.5) on two consecutive occasions.

Note: although the INR may be measured each day after starting warfarin, a meaningful INR can only be obtained 3–4 days after starting treatment.

Then, twice weekly for 1–2 weeks, followed by weekly measurements until at least two INR measurements are within the therapeutic range.

Thereafter, depending on the stability of the INR, at longer intervals (for example, up to every 12 weeks, if agreed locally). Once a stable warfarin dose that controls the INR has been established, changes in dose are seldom required.

That seems right does it not?

Yesterday, a worker at the clinic told me he had been put on Warfarin seven years ago. When he started his hospital measured INR for the first seven days - each day.

This clinic cannot possibly achieve the NICE ideal, - it is open only on Mondays, Wednesdays and Fridays - and Mondays is reserved for "postal" patients. I believe they use INRStar software, and it is the computer operators who are prescribing for me - but if you have never attained the target, I can't see what help that would be. Could there be an over-reliance on computer programme? (Having worked in the NHS and also in computers, my trust level of IT -especially NHS IT is rock bottom).

I could accept weekly measurements, but less frequent measurements when the INR is too high does not sound right.

But I'm a newbie really - got warfarin for 3 months 10 years ago and took no notice of it back then.

What do more folk, more knowledgeable of warfarin and INR's think?

34 Replies

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  • Hi, I think you are right that your Anticoagulating Clinic is not safe at all. Not for you with APS. You are also talking of a break in the beginning. You stopped the Warfarin after you had started it! I have learnt that you must never stop warfarin but perhaps it is different at the very beginning

    I hope someone else will answer how you are going to do with this problem.

    I do hope you have an APS-specialist that understands your illness. You are well aware of your situation and that sounds very good indeed. Please come back to us and tell us how it goes for you.

    I wish you luck. Take care. Kerstin in Stockholm

  • I was switched from warfarin to rivaroxaban - but stopped that 4 days later.

  • Hi Kerstin,

    Thanks for that - it kind of confirms my suspicion. The Lupus Unit at St Thomas's (Professor Khamashta) is seeing me for the APS - but the Anti-Coagulation clinic is local.

    The warfarin was stopped a week after starting because I got loads of rashes and got quite ill. I was put on rivaroxaban instead. I continued to get even more ill - so I stopped that. Then three weeks later I was still feeling like death - and worked out the illness was coincidental and not due to the warfarin. So I started again. The rash has gone (it could have been a Lupus flare though I tested negative for Lupus) but I am still quite ill. Part of this is a nasty flu.

    On the other hand warfarin has improved some very long-term symptoms spectacularly. Heparin works well with me too - but I would prefer not injecting if possible.

    The INR clinic monitoring frequency seems to be a case of one size fits all - no matter that you have never been in the target range.

  • Hi, I hope I can follow you now ...... You are on warfarin and you are not ill because of the warfarin, Good. You do not know if you have had a Lupus flare. You have part of a flu eventually.......The Warfarin has improved a lot of your symtoms spectacularly......( It did that to me also.) Good.

    So I would say that if you have a coagulation clinic that can work together with your doctor in charge of your APS (prof Khamashta at The Lupus Unit of St Thomas´s ) you would be well.

    So if I were you I would have a talk with prof Khamashta and tell him this. He will certainly understand that you must have help.

    Take good care . Kerstin

  • I have recently moved from my local anticoagulant clinic for that very reason. I was not happy with their lack of knowledge of APS, they would leave me for weeks between tests, had no idea how to deal with a TIA, yet they did not approve of me self testing.

    I now see a haematologist at the same hospital as my rheumatologist and the anti coagulation clinic there is happy for me to self test, with 6 monthly visits to calibrate my machine.

  • Oh I am so glad for you that you are safisfied. My first anticoagulation clinic did not know what APS was. But it often has to be a fight to get what you want.

    Best wishes from Kerstin in Stockholm

  • Yes. I am seeing Professor Khamashta soon. My appointment has been brought forward from November to June 20th. The reason is the local hospital has written to him about the rash - then they thought it was warfarin. But that information is out of date - warfarin almost certainly was not the cause. So I am seeing him rather unnecessarily really. Not sure what he can do - he hasn't referred me to the anticoagulation clinic - he has asked the GP to do that. And I expect the GP has a contract with one anticoagulation clinic only.

    Any mention of self-testing is met by blank stares - and someone asking "What do you mean by self-testing exactly?"

    I get my own Coaguchek XS machine from Roche and get prescribed maybe 48 strips a year, and you check that the machine is calibrated correctly periodically. "No we don't support anything like that." What a thing to ask!

    I suppose the question for group members is - does any hospital follow the 2013 NICE anticoagulation guidelines when starting warfarin nowadays?

  • There are several persons with APS that can have a stable APS. You must absolutely change that anticoagulating clinic. Good that you are going to see the professor Khamashta on the 20th of June already! You must be able to ask him for help if you cannot find a solution before that,

    Hope someone can tell you how to do. I cannot.

    Good luck from Kerstin

  • marco-mustard - you must go to your GP and tell him /her that the treatment you are receiving at the coag clinic is unacceptable and could actually be putting you in danger. Your GP has overall responsibility for your health so if your clinic are only treating you as if you have AF and don't understand APS then that is not acceptable. Ask to be referred to the consultant Haematologist in charge of the Clinic and if you get blank stares INSIST because they do have one and they WILL know about APS. If you have to print off the guidelines on this site above for Haematologists and quote that at them then do that. If all that fails tell them you are going to write to your CCG and say that unless they can provide adequate treatment for you then you might be forced to report them to NHS England. Unfortunately we have to do our own research about what is and is not acceptable and then fight for it.

    I made a similar fuss about my local clinic by writing to the CEO of the Hospital Trust. 5 letters went by with stupid replies that said nothing. I refused to accept it and said I would go to my MP and then copied my response into my MP. That brought a response which was to invite me to a meeting with the head of the department. Following that they made some changes after the CEO got off his backside and actually went and looked at the clinic for himself and called it "Toxic"!

    I was then brought on to a steering committee for the complete redesign of a new department. So you see you do sometimes have to stamp your feet quite hard and be persistent! :-D

    Good Luck!

  • That was the answer I hoped Marco-mustard could have! I like your "stile" APsnotFab.

    Kerstin

  • Hi.

    I accept that you are anxious and I would be too. However, the clinics are only staffed by nurses, and very few of them have heard of APS. It is relatively new. Most of the patients they see WILL be able to reach a stable INR, but us Hughies are different as our blood is always changing. My consultant said that our blood will always be changing and it is not good to keep testing too often and changing our dose. The body needs to get used to one dose. Also, when you change your dose it can take up to 72 hours to register.

    It is all fun and games! You will get used to it! I am glad it helped your symptoms. The same thing happened to me. i stopped feeling like I had early onset Altzheimers!

    I feel that we have a responsibility to educate the clinics for the next patient. I have done this for mine. I am fortunate because I self test, but I know of at least one area where the policy is NO self testing. Where are you situated? In an ideal world everyone would follow NICE guidelines but we don't live in an ideal world sadly.

    Good luck with it all. Warfarin treatment is a very inexact science, but I personally am very grateful for it. It helps me lead a relatively normal life.

    Blessings Ann

  • I do agree with you. Thank you for your beautiful input. I also selftest here in Sweden.

    Best wishes from Kerstin in Stockholm

  • I have been on warfarin since 1992 and I was tested every day for a week and then 2 then 7 and depending on my latest result I can be 2 months now. One thing you will have to look at as well is the medicine you take and what foods you eat? A lot of dark leafy veg will affect warfarin and cranberries are a no no, alcohol all sorts of things needed to be looked at. including vitamins etc.

    I hope you get it sorted out anything under 5 is not good but not that dangerous unless you are a knife throwers assistant.

    Be Well

  • Can you say which hospital - where they tested every day for a week? (Quite understand if you would rather not say)

  • Going back to the GP will not be possible until July or August - there will be a Locum who will be reluctant to "interfere". And when the GP does get back, he as I say, will probably not refer me anywhere else for contractual reasons. However the Clinical Commissioning Group is a possibilty. They have an incentive to get value for money.

    Then there is PALS - the advocacy service of the hospital. They can be helpful. Or there is this fairly new thing - Local Authority run - Healthwatch. I believe they are intended to be the replacement for Community Health Councils which were sadly abolished.

    I have written a letter to the Clinic (it is not I think consultant run) questioning my dosage, and pointing out the NICE guidelines. The fact that this letter has not been responded to - nor does a copy appear in my notes leads me to suspect that attitudes may be hardening. "Complain and there will be come-back" should be the motto of this hospital. And I have had years of experience with NHS complaints-avoidance tactics, which are manifold and mature. I would be contacting my MP sooner rather than later.

    Thanks for all your help. London Lass - oh I see. You are maintaining that APS patients - unlike others on warfarin - should be kept on a consistent dose and not measured often? So the NICE guidelines should not apply to us? In that case the clinic is doing the right thing. (I do know about Hospital workings - but very little about APS. Not read the books - starting with Sticky Blood - yet!)

    For these two weeks - my dosage is 5Mg daily. Last instructions (for a week) was 6Mg except Mondays, Wednesdays and Fridays when it was 5Mg. I questioned this - saying my INR level would depend partly on which day of the week the measurement had been taken.

  • Our hospital does not do standard warfarin tests on a Friday?

  • Interesting off-cut. "anything under 5 is not good but not that dangerous" Yeah, I think 0.4 away from target - and it is going in the right direction is not anything to get too worried about now - but the road to where we are now, is not one that should have been chosen at the outset.

    No doubt the Clinic will say we are doing the best we can with the resources we have. Meaning that those resources are far too little for the several thousand patients they have and 25 new cases a week. I suspect there is a lot of hope that the novel anticoagulants will prove to be a good replacement for warfarin in most cases. So improvement of the existing service comes way below shrinking the workload needed per patient as a priority.

  • The new no blood tests ones are the way forward but I am not impressed that they do not have an antidote for them like warfarin. I know it has a low life cycle but what if it is at the start you have a problem?

    Article on the discovery of Warfarin:

    onlinelibrary.wiley.com/doi...

  • Thank you Offcut for that interesting article "Discovery of heparin and warfarin".! (Historical Review)

    Best wishes from Kerstin in Stockholm

  • I've also been on Warfarin for about 12 weeks (with target of 2-3) and at the start, I was tested twice a week for about six weeks then once a week with unstable inr's . Finally, I stayed the target range then was tested two weeks later and last time was told to come back in three weeks. That's 1 week from this Tuesday. I was told I will eventually going in every month. It is scary to wait longer than I'm used to but I feel that I have to trust them. I am in the US and don't know anyone who does self testing but after having a stroke in March, I do worry.

    I wish you the best. Keep looking until you find someone who is monitoring you to the point where you feel comfortable. My neurologist starting monitoring me after stroke then my GP (who know nothing about APS-zero) and then I found an Coagulation Clinic who will only see me until April when I'm going to another GP who is private. It's a hard journey but people here have helped me tremendously. I wish you well.

  • Hi Loretta, I Think you should be tested more often than every three week. At least once a week. Best would be if you could selftest. I wish i could help you more. I "Think" I have heard that it has to do with insurance and 3 months........ but not sure. Could you find out. Can someone help you.

    You have only been on Warfarin for 12 weeks and also at a low therapeutic range (2.0-3.0). Most of us must be over 3.0 to feel OK. I am sorry to make you worried but you must be tested every week. I have always been tested every week. That coagulation clinic and GP know nothing about APS

    Hope someone here knows about the US "market" or do you have some relatives that could look for info?

    I think you should have an APS-doctor. Neurologists do not always know this illness. Rheumatologists and Hematologists do.

    I do not want to worry you but you must get a lab result more often than every month as they have suggested. Every second week is too rare also.

    Let us hear how it goes for you please Loretta.

    My very best wishes from Kerstin .

  • Thanks. Its definitely a process. The APS MD's are too far away from my home unfortunately but I do have a fabulous rheumatologist who I'll see in 2 wks but she doesn't do testing. Will eventually check into getting into self testing. I'll first call my insurance company. Then take it from there.

  • Thats sounds good if she understands your APS. Do you have both Plaguenil and Warfarin? Selftesting is fantastic. Hope you can talk to your Rheumatologist and tell her that they intend to test you only every month.

    Kerstin

  • I am not medical, and we are all different, so I am not advocating a consistent dose. I am just quoting my consultant.

    Alternate days is to balance the dose out over a week, as some people cannot get 0.5mg tablets. Don't think it makes a lot of difference which day you are tested.

    I think reading the books would help you.

    As I repeat, this is a very inexact science. Yes, I think we do need to subscribe to NICE, but as I said we don't live in an ideal world.

    Hoping you can sort it all soon.

    Loretta, sounds like you have got it just right. Well done to your team

    As I said in my talk, praise when they get it right!

    Blessings Ann

  • Loretta, in my experience if you are stable, 3 weeks to a month is fine, Good to be free of testing and get on with life

    But this is a personal opinion based on my own experience, and what my group have told me over the years.

    Blessings Ann

  • Yes, on warfarin, plaquenil (400 mg/day) and lipitor--stated on 80 mg of lipitor out of hosp then reduced to 10 mg (leg pains at higher doses) Now until I see my cardiologist in a week taking 5 mg. Don't have high cholesterol but am told that the lipitor provides extra protection for the heart.

  • May I ask you Loretta why you are on Plaquenil also? Do you have Lupus?

    My Rheumatologist wanted me on statins. I am on 10 mg. Had leg pains the first months but now OK. I Think it is good for us over 65.Did you say you were 68? Have I forgotten? I have diastolic disfunction also. My Cholesterol have reduced a lot. I did not have high Cholesterol but as I have APS it is wise to keep it low.

  • 67 now--68 in November -:) I was dx with APS in March and Lupus Factor. Have my 12 week follow up blood test on June 23rd so confirm Lupus. I was put on Plaquenil because of my symptoms. Well off to enjoy this gorgeous day New York City. Have a great day.

  • Enjoy your day!

    We have had a princess christening here this beautiful day. The father is from the US. Followed it on TV today. Princess Madeleine (our King and Queens youngest girls first baby-girl)

    Kerstin in Stockholm

  • I'm sure you enjoyed. Sounds like fun!

  • Correction - I read that the Clinic use DAWN software - not INRStar as used elsewhere in the Trusts hospitals.

  • Hi, yes you need to be monitored more frequently especially if inr is unstable, mine has been all month, I've been 2.4 1st wk, then 2.8 next last wk was 4.2! They have checked mine every wk, have another one on Thursday.

    My GPS & nurses are very good & will often leave it to me when come in as they have realised we understand our symptoms of when it's high or low..... Was a struggle at 1st so keep persisting,don't give up.

    I have my own machine I bought myself & I have the strips on nhs...that too was a struggle! But you have to persevere if you need anything I've learned!

    Good luck, Sue

  • I do agee. We have to persevere (that was a new word for me)!!

    Best wishes to you Suzy from Kerstin

  • Lol...well done Kerstin :)

    All the best to you too x

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