worried about my INR.RANGE

[meatboy]

having had a new aota valve replacement sept.2007,as its a mechanical valve I have to take warfarin for life.

before moving to Thailand 2009 my inr.range was set at 13mg.a week.

no trouble in the uk.and 8yrs.in Thailand on orfarin,checked regular at a blood clinic.

then after a few bouts of seizure's and was told not to drive I bought my own blood testing machine a COAGUCHEK XS [ROCHE] not cheap with the test strips alone costing 200bht.a time,but it was very convienient to do it at home.since nov.i have to go back and fo to their inr.clinic at the hospital.for check ups.

now for the problem,at first the hospital tried to set a different range,they said that the medication they prescribed for me would interfere with the warfarin.

but its now april and I was there yesterday and they still cant get it right,dangerously low 1.7 when it should be 2-3.

last month I decided to up the doseage my self as I have managed it before for 9yrs.and after 3 tests it was well within may range.

but what I am worried about as its low [by their tests is a blood clot,with my blood being too thick by their tests.

what is the problem? is their testing kit to blame or is it the cheap cheap medication [MAFORAN] half the price of ORFARIN.

tomorrow I will check it again as their new setting will be the same dosage as what I set  over the last month. was 15.75mg.now put up to 16.5mg.

I have to say the pharmacist was very alarmed at when she saw my record,and asked the doctor why as it taken so long to set the range[2-3] no comment.

as anybody found MAFORAN to be not up to standad.

or could it be my machine,i did test it once against their's and it was spot on.when the doseage was low.

now this one is for our dear friend of all members is,SHERYL,the medication I take to control the seizure's is DILANTIN this play's havoc with many side affects including warfarin.if it is this that's giving me not the correct test why has the doctor not mentioned this.

so if anyone can help I would be very gratefull. next test at the hospital 23may.[6weekks]

[Langsuan Man]

Since I can't really understand what  you are going on about, testing at home, testing at the hospital, warfarin ,  MAFORAN, etc. I can only tell you my experience with Warfarin and INR for DVT's in Thailand

 

My US doctor required that my INR range be between 2-3 and I was tested every two weeks at a lab in Pattaya for one year and the next year US Medicare paid for a machine and the testing service that reported my bi-monthly results to my US doctor .  During this time I was exclusively on generic Warfarin or Coumadin as known in the US at 5 mg per day for an INR of 2.5 most of the time.  Any large variations of that reading would require a reduction or increase in my daily dosage.  But showing a 1.7 is not that significant , since it doesn't take much warfarin to raise it up to the 2.0 minimum level.  You need to stay in the correct range, but don't freak out is your levels are off since diet, exercise, and many other things can throw your reading off.  Now if you are consistently at 1.7 then it is pretty obvious that you need an increase in dosage.

 

But the bottom line is that you should be managing your levels, not some clinic or doctor that is not there every day to control you dosage or to know that you  had a hankering for a chefs salad the day before your test, which would throw your numbers off  

[meatboy]

thanks for your reply.i have been managing my own warfarin doseage for 9yrs.that was till I went into hospital nov.2017

suffering from seizure's,and the medication they prescribed for me to stop the seizure's [Dilantin] is one of the side affects that can interfere with warfarin.so its been 5months and the inr.clinic at the hospital seems they either they have not got the brains to work out how much the Dilantin is affecting my INR.RANGE 2-3.or their testing is not right.

before going into hospital I was taking orfarin,but the hospital changed it to maforan.

at 73yrs.old nothing has changed in my lifestyle for the past 10yrs.only I have stopped drinking nearly 3yrs.ago.

you should know that if you interfere with the medication the hospital prescribe's they wont be happy.

so the next time I have an emergency they might tell me to F. off.

[meatboy]

oh one thing I must tell you is all the phamarcy's including the hospital only have 3mg.or 5mg.tablets they think eg.

you need 15mg.they say don't cut them take 5days at 3mg.well as the doseage has got to be as near as you can get to  an every day amount,that is important to control the blood flow to my valve.if by being too low and I get a blood clot on the valve its to the temple I go,and not the hospital. GOT IT.?

[geriatrickid]

Please consider this;

 

1. As mentioned above, diet has an influence.My biggest complaint with potent drugs like this is that ongoing dietary counseling is never provided. We are constantly told to eat diets rich in leafy green vegetables and to use healthy oils like canola and olive. All provide high vitamin K. which can  disrupt  the INR - clotting results. Care  should be given to how much  of the leafy greens are consumed . Olive oil and canola oil can still be consumed subject to the Vitamin K being deactivated through exposure to fluorescent lights or sunlight for 48 hours.However, one does need  Vitamin K.  This sort of thing  is difficult to manage on one's own. Who can help? A trained & experienced dietician/nutritionist who  works with heart patients and knows the  drugs being prescribed. Well worth the time of a meeting with  one.

 

2. Drug contradictions: Many drugs interact and impact the efficacy and metabolism of other drugs. Sometimes  doctors know their drugs, and sometimes they do not. This is where a qualified pharmacist ( a real one, and one who has experience with cardiac patients is helpful.)  I work with drugs, but if you asked me questions on drugs I have no experience with, I could answer incorrectly and kill someone. This is why I like the concept of integrated teams that treat a patient. Ask and keep asking the team who care for you.

 

I do note that you take Dilantin. (Phenytoin Sodium) Does the physician prescribing the Coumadin know this? I ask because the   monograph for dilantin states that there is the possibility of a drug interaction.

Drugs Whose Blood Serum Levels and/or Effects May be Altered by Phenytoin

Drug Class: Coumarin anticoagulants Product: Warfarin.

 

When in doubt or presented with issues of concern, always consult with the attending physician and the  qualified hospital pharmacist. People can forget or not know a patients file. Make sure they do the file.

 

 

 

[meatboy]

28 minutes ago, geriatrickid said:

Please consider this;

 

1. As mentioned above, diet has an influence.My biggest complaint with potent drugs like this is that ongoing dietary counseling is never provided. We are constantly told to eat diets rich in leafy green vegetables and to use healthy oils like canola and olive. All provide high vitamin K. which can  disrupt  the INR - clotting results. Care  should be given to how much  of the leafy greens are consumed . Olive oil and canola oil can still be consumed subject to the Vitamin K being deactivated through exposure to fluorescent lights or sunlight for 48 hours.However, one does need  Vitamin K.  This sort of thing  is difficult to manage on one's own. Who can help? A trained & experienced dietician/nutritionist who  works with heart patients and knows the  drugs being prescribed. Well worth the time of a meeting with  one.

 

2. Drug contradictions: Many drugs interact and impact the efficacy and metabolism of other drugs. Sometimes  doctors know their drugs, and sometimes they do not. This is where a qualified pharmacist ( a real one, and one who has experience with cardiac patients is helpful.)  I work with drugs, but if you asked me questions on drugs I have no experience with, I could answer incorrectly and kill someone. This is why I like the concept of integrated teams that treat a patient. Ask and keep asking the team who care for you.

 

I do note that you take Dilantin. (Phenytoin Sodium) Does the physician prescribing the Coumadin know this? I ask because the   monograph for dilantin states that there is the possibility of a drug interaction.

Drugs Whose Blood Serum Levels and/or Effects May be Altered by Phenytoin

Drug Class: Coumarin anticoagulants Product: Warfarin.

 

When in doubt or presented with issues of concern, always consult with the attending physician and the  qualified hospital pharmacist. People can forget or not know a patients file. Make sure they do the file.

 

 

 

thanks a lot for your reply,i keep mentioning it every time I see the doctor,that I think its the Dilantin side affects that is causing havoc,so far I have experienced bad constipation,fever&with a bad cough,tremors,balance, I cannot sign my name anymore[the bank has noticed this] I did read that my body will get used to the side affects,but as one goes another comes along,as long as the tabs.stop the seizure's that's ok.by me.but my tablet count keeps going up,apart what I have always took,last week I have to take THIAMINE HYDOCHOLIDE [10 WEEKS]

[Sheryl]

Dilantin (phenytoin) is very well known to interact with warfarin. In the majority of cases the effect is to increase the effect of the warfarin which is why the hospital initially wanted to lower your dose.

 

However the opposite effect can also occur, with the dilantin partially blocking the effect of the warfarin as the two drugs compete for the same metabolic pathways, and it sounds like this is what has occurred in your case. To further complicate matters the dilantin-warfarin interaction can be erratic, resulting in elevated INR at some times (by potentiating the effect of warfarin) and lower INR at other times (by partially blocking the metabolism of warfarin) in the same patient.

 

This makes stabilizing INR in people taking both drugs very, very difficult.  Even if you get to desired INR range you may find a week later that you are again out of range and could be in either direction.

 

In addition, the warfarin can interfere with the effectiveness of the dilantin and you may not get optimal seizure control.

 

I suspect that the intrinsic problem of being on these two drugs is more of an issue than the brand of warfarin you are taking but no harm in switching over to Orafrin which is also an inexpensive locally made brand of warfarin but more widely used/sold brand and  I can say from the experience of many patients, there does not seem to be a quality issue with it (not saying there is one with Marforan, I just haven't had much experience or reports on it).

 

However my main advice would be to discuss with your neurologist a change in anti-seizure medication. Tell him/her that ever since going on it you have had great trouble in stabilizing your INR levels.  While dilantin is a common, low cost first line medication for seizure control in general, it is not IMO an optional choice for someone on warfarin.

 

One alternative anti-seizure drug that has no interaction with warfarin is  Gabapentin.  Although there are locally made brands of it it will cost more than dilantin, but likely well worth it and what you may save in extra hospital visits and lab tests (and potentially even serious hospitalizations) may well offset the difference.

 

If you were treated in a government hospital, they are under orders to try to use the lowest cost drugs and reserve gabapentin  for special cases. This order is for Thai patients since the government is paying the cost of the meds and needs to control costs.. As a foreigner you are paying out of pocket for the drugs, so this should not matter. Plus you have grounds to justify it since dilantin has had negative interaction with warfarin leading to negative clinical outcome.

 

 

 

 

[meatboy]

17 minutes ago, Sheryl said:

Dilantin (phenytoin) is very well known to interact with warfarin. In the majority of cases the effect is to increase the effect of the warfarin which is why the hospital initially wanted to lower your dose.

 

However the opposite effect can also occur, with the dilantin partially blocking the effect of the warfarin as the two drugs compete for the same metabolic pathways, and it sounds like this is what has occurred in your case. To further complicate matters the dilantin-warfarin interaction can be erratic, resulting in elevated INR at some times (by potentiating the effect of warfarin) and lower INR at other times (by partially blocking the metabolism of warfarin) in the same patient.

 

This makes stabilizing INR in people taking both drugs very, very difficult.  Even if you get to desired INR range you may find a week later that you are again out of range and could be in either direction.

 

In addition, the warfarin can interfere with the effectiveness of the dilantin and you may not get optimal seizure control.

 

I suspect that the intrinsic problem of being on these two drugs is more of an issue than the brand of warfarin you are taking but no harm in switching over to Orafrin which is also an inexpensive locally made brand of warfarin but more widely used/sold brand and  I can say from the experience of many patients, there does not seem to be a quality issue with it (not saying there is one with Marforan, I just haven't had much experience or reports on it).

 

However my main advice would be to discuss with your neurologist a change in anti-seizure medication. Tell him/her that ever since going on it you have had great trouble in stabilizing your INR levels.  While dilantin is a common, low cost first line medication for seizure control in general, it is not IMO an optional choice for someone on warfarin.

 

One alternative anti-seizure drug that has no interaction with warfarin is  Gabapentin.  Although there are locally made brands of it it will cost more than dilantin, but likely well worth it and what you may save in extra hospital visits and lab tests (and potentially even serious hospitalizations) may well offset the difference.

 

If you were treated in a government hospital, they are under orders to try to use the lowest cost drugs and reserve gabapentin  for special cases. This order is for Thai patients since the government is paying the cost of the meds and needs to control costs.. As a foreigner you are paying out of pocket for the drugs, so this should not matter. Plus you have grounds to justify it since dilantin has had negative interaction with warfarin leading to negative clinical outcome.

 

 

 

 

thank you very much,i can finely see where I am going,i am not worried about the cost as the only tablets I have from the hospital are maforan and yes they are very cheap,yesterday's 80tabs were only 180bht.half the price of orfarin.

now this is a bit tricky as from today until next tues.its emergency only. and the doctor wont be available till wed.

I will go back to taking orfarin as soon as I tell the hospital.i am not sure if the pharmacy's are closed,but the one where I get all my meds.siam pharmacy are not answering the phone.the wife has always found them very good,checking everything before they give you anything.

meatboy.

[Sheryl]

You can make a marforan to orfarin switch on your iwn (if you can find any open pharmacy) as doses are equivalent and same generic.

Where you need medical guidance is in changing anti-seizure medication.

BTW did they identify cause for new onset of seizures? In someone without history of epilepsy this warrants pretty extensive investigations.


Sent from my SM-J701F using Thailand Forum - Thaivisa mobile app

[meatboy]

2 hours ago, Sheryl said:

You can make a marforan to orfarin switch on your iwn (if you can find any open pharmacy) as doses are equivalent and same generic.

Where you need medical guidance is in changing anti-seizure medication.

BTW did they identify cause for new onset of seizures? In someone without history of epilepsy this warrants pretty extensive investigations.


Sent from my SM-J701F using Thailand Forum - Thaivisa mobile app
 

after 3ct.brain scans they couldn't find anything wrong,the last scan was nov.2017 after 5 seizure's in one day.

I have about 60 x 3mg.of orfarin dated to oct.2019.

[meatboy]

On ‎4‎/‎12‎/‎2018 at 2:44 PM, Sheryl said:

You can make a marforan to orfarin switch on your iwn (if you can find any open pharmacy) as doses are equivalent and same generic.

Where you need medical guidance is in changing anti-seizure medication.

BTW did they identify cause for new onset of seizures? In someone without history of epilepsy this warrants pretty extensive investigations.


Sent from my SM-J701F using Thailand Forum - Thaivisa mobile app
 

thanks Sheryl,i have an appointment at thepperat thurs.hopefully I will get the treatment I need.i thought this hospital was decent enough to register when the 2,000bht.scheme was introduced,but I am starting to think otherwise.

for the doctor to prescribe dillantin to combat the seizure's,with the medication I take I don't know what she was thinking.it affects 4 of my meds.including my channel blockers which I have to take for life,along with the main one being WARFARIN.its been 5 months and my doseage is dangerously low which can cause a blood clot on my valve.

yet she has ignored this.as soon as the pharmacy opens I will get GABAPENTIN.as it has no interactions with any of my medication.so can you tell me Sheryl once I go onto gabapentin I will have to revalue my warfarin dose,oringinally it was 

13mg.a week,but I am now taking 16mg.i have my own blood testing machine so how long before I do the first test.

[Langsuan Man]

5 minutes ago, meatboy said:

i have my own blood testing machine so how long before I do the first test.

Minimum, one week (7 days) optimum two weeks (14 days)

[meatboy]

Just now, Langsuan Man said:

Minimum, one week (7 days) optimum two weeks (14 days)

thanks LM.just my luck that the main pharmacy in korat CLOSED FOR HOLLIDAYS so is the hospital [emergency only]

but I doubt very much they will have what I need.

take note everyone on dillantin has many side affects with interactions.

[meatboy]

On ‎4‎/‎15‎/‎2018 at 8:53 AM, meatboy said:

thanks LM.just my luck that the main pharmacy in korat CLOSED FOR HOLLIDAYS so is the hospital [emergency only]

but I doubt very much they will have what I need.

take note everyone on dillantin has many side affects with interactions.

thanks to Sheryl,and my doctor at a [GOVERMENT HOSPITAL] my suffering the side affects I have been getting the past 5months could be over.i went yesterday and demanded I see the doctor who has been treating me,and told her my concerns first I definatly think that if you use a government hospital what you get is what they give you.well its NOT.i managed to get one of the best medications,that I am certain will help,meds.that most pharmacy's only stock on order and at triple the price,i can only imagine what these would have cost me at a private hospital. if anybody has been taking these tablets for seizure's let me know what they are paying for KEPPRA.and I am certain the price I paid will not come nowhere near.

[Sheryl]

Good choice. There is no known interaction between Keppra and warfarin.

 

As I am sure you know, you need to carefully monitor your INR now as warfarin need may change.

[meatboy]

31 minutes ago, Sheryl said:

Good choice. There is no known interaction between Keppra and warfarin.

 

As I am sure you know, you need to carefully monitor your INR now as warfarin need may change.

thanks Sheryl,the doctor altered it and she know's I have a machine so that comes easy.they will test again Monday,also they will do a CTA femoral artery run off to check to see where the leg pain is coming from.

[meatboy]

On ‎4‎/‎18‎/‎2018 at 1:56 PM, meatboy said:

thanks Sheryl,the doctor altered it and she know's I have a machine so that comes easy.they will test again Monday,also they will do a CTA femoral artery run off to check to see where the leg pain is coming from.

done yesterday[not cheap] wait now till next Monday.only thing bothering me now is a very chesty cough.[11days now]

with the amount of people at the hospital every day,the air must be full of virus's.

Edited April 24, 2018 by meatboy

[meatboy]

the results of my CTA scan wasn't tooooooooooo bad.might need a stent,as I have some artery problem in the lower extremitites and the bilateral anterior arteries,and I have been refered to another hospital [vascular doctor]

now what I consider my main concern,as the doctor took me off Dilantin which was interfering with my warfarin range.

she changed the range back to 12,i told her that is TOO low but she would not listen.tomorrow I shall go to the INR clinic to get tested,and if my self test I done today is correct I will tell her she will not treat me again as she put my life  in danger.

this also could be affecting my leg arteries,as the result of my CTA SCAN mentioned the blood flow many times in the report [English]

[meatboy]

21 hours ago, meatboy said:

the results of my CTA scan wasn't tooooooooooo bad.might need a stent,as I have some artery problem in the lower extremitites and the bilateral anterior arteries,and I have been refered to another hospital [vascular doctor]

now what I consider my main concern,as the doctor took me off Dilantin which was interfering with my warfarin range.

she changed the range back to 12,i told her that is TOO low but she would not listen.tomorrow I shall go to the INR clinic to get tested,and if my self test I done today is correct I will tell her she will not treat me again as she put my life  in danger.

this also could be affecting my leg arteries,as the result of my CTA SCAN mentioned the blood flow many times in the report [English]

that will be the last time I see her,does she understand what INR means? NO, my test I done yesterday frightened me as it was as low as,1.3 that is critical for me to go that LOW.but it was exactly the same today,so it wasn't my machine.first I spoke with the phamarcist and told her,i had been doing my own dose of warfarin for over 8yrs.without any mistake,yet my life has been put at risk by a professional doctor who doesn't understand.so all them that use a government hospital be on your GUARD.

[Sheryl]

I assume you mean to say 1.2, not 12!

 

Usual target range is somewhere between 2-3.

 

 

[meatboy]

On ‎5‎/‎2‎/‎2018 at 7:23 PM, Sheryl said:

I assume you mean to say 1.2, not 12!

 

Usual target range is somewhere between 2-3.

 

 

a bit late replying but yesterday was a long day,went to see a vascular doctor,who was more than alarmed at what my INR.was .my own test 1.3 TUES. range is supposed to be 2-3.so I thought my self tester must be faulty as surely 1.3 cant be right.so I went to the INR clinic at the hospital and to see the doctor.the hospitals test,1.3 so it wasn't my machine but doctors incompetence.