Sunday Times On Strokes
They have a series of articles on strokes today. One in particular talks about the new drugs to replace Warfarin. Information for the article was provided by Boehringer Ingelheim.
So who makes one of the new drugs?
You got it in one!
Am I changing?
No! All the doctors I’ve seen from the stars that appear on TV, to the newly qualified have advised me against them.
The reason is that it took us many years to know all the Warfarin problems. The biggest is actually people getting rather mixed up, as to what is the dose.
Solving that is a managememt problem and doesn’t require a new drug with unknown side-effects.
In the article, it says that with the new drugs, the great advantage is that you take one a day. I have taken the same dose of Warfarin for over a year now and the dose is 5 mg (pink) most days and 4 mg (1 blue and 1 brown) on Saturday and Monday.
What could be simpler?
Diet and Warfarin
With the scare from Denmark about Marmite, I thought I’d check that my diet was OK? Especially, as I’m on a gluten free diet and take Warfarin.
It can’t be too bad, as I’ve been on the same level of Warfarin for about seven or eight months now and the last test was in the correct range.
I found this informative page in the Grown Up Congenital Heart Patients Association web site.
I liked the section about alcohol.
The interaction between alcohol and warfarin is complex. Alcohol acts as a mild anticoagulant. It also can affect the metabolism of the liver, which s important tor metabolising warfarin. As a rule of rhumb, two to three drinks per day – glasses of wine. beer etc -(typical cardiologist input) are unlikely to affect your warfarin levels. Intermittent binge drinking (typical medical student input) leads to an increase in INR (international ratio, the measurement used to check warfarin levels in the blood) due to warfarin being metabolised more slowly. Chronic heavy alcohol intake (Harley Street cardiologist input just joking!) results in a lower warfarin level because the alcohol increases the metabolism of warfarin.
It’s good to see a bit of humour in sites like this.
But then it says it’s a site for grown ups, by which they mean young people and adults.
INR Test – 23rd May 2011
Result: 2.3
Dosing Recommendation: 4.8 mg/day
Next INR Test interval: 56 days
Repeat INR Test on 18th July 2011 at 11:00.
Be Nice To Nanny and You’ll Get Your Warfarin!
As I’ve said before Warfarin testing in this country and I suspect most of the world is complicated and it may be prone to error. Two respected doctors have told me that.
Today, I took a prescription to Boots to get some more Warfarin tablets. They wanted to see my yellow book, which I hadn’t got with me. So I got the third degree! I wasn’t rude, but as a scientist who understands the way Warfarin works well, I resent being treated like an idiot. It’s not the pharmacist’s fault, but the person, who made up the new rules.
Now, my INR has been spot on for months and the dosage has only changed marginally since December last year. That change was when I changed surgeries and the new one now does the tests themselves on a small monitor, whereas the previous surgery did it by blood tests that were analysed by the hospital. The change is that previously, I was on 5 mg. a day and 4 mg. at weekends, and now it’s 5 mg. a day and 4 mg. on Saturdays and Mondays. Or as the computer printout says, one 3 mg. and one 1 mg. on Saturdays and Mondays. I don’t like the inference that I can’t work out how I can give myself a 4 mg. dose, with 3 mg. and 1 mg. tablets.
Thev pharmacist indicated that next time if I didn’t bring the book, I wouldn’t get the Warfarin.
I actually think the next time I go, I might not take it, as I prefer to keep it safe at home. After all suppose I dropped it, I would then have to go back to the doctor for another book. But I would take a photocopy of my last INR test result. To me that is much more important as it carries the date of my next test.
One thing that is worth noting is that testing method one using blood tests and analysis at the local hospital, said I should be on 4.8 mg. per day. On the other hand testing method two using an electronic monitor in the surgery, said the dose should 4.8 mg per day.
In other words, both methods carried out in a correct professional manner gave exactly the same result.
INR Test – 11th April 2011
Result: 2.2
Dosing Recommendation: 4.8 mg/day
Next INR Test interval: 42 days
Repeat INR Test on 23rd May 2011 at 11:10.
Do We Have Too Many Nurses?
I have used the NHS a lot in the last three years, what with the death of my wife and son to cancer and a couple of strokes.
In many cases I have had appointments with doctors and other healthcare professionals and whereas a few years ago, they would have had a nurse or a technical assistant to work with them, now they usually work alone with sophisticated equipment.
I am on Warfarin and at my previous surgery, a nurse used to take a blood test once a fortnight, which was sent to the local hospital for analysis. Now, my new GP does it himself with a small instrument that gives results immediately.
So is technology taking over from nurses?
To illustrate this BBC Breakfast has just shown how to use a heart defibrillator. It all seemed fairly simple and very much led by an intelligent machine.
A Coeliac’s Questions About Warfarin
My cardiologist, reckons that if I can keep to the Warfarin regime, then I won’t have another stroke and his advice is also reflected by other doctors.
I also asked my stroke doctor about the new drugs coming in, more out of curiosity than anything else, and it seemed he was not in favour of them, because we’re still uncertain about the long-term effects of the new drugs.
Of late though, I’ve been feeling wretched a lot of the time, with what is best described as flu-like symptoms and a very itchy skin, a rash and bad dandruff in my beard, just like I used to have before I went gluten-free. My toenails are bad and brittle although my fingernails have improved since Christmas.
I had put it all down to North London’s version of man-flu and the general cold and bad weather. Athough on some trips out of London, like the one to Barnsley, I seemed to feel better.
So I looked up the Mayo Clinic’s web site on Warfarin side effects. I’m not a great one for some health web sites, but this one is generally fairly reliable.
But it did seem that some of my problems could be down to the Warfarin. On the other hand they may not be.
But I think I might make one or two modifications to my lifestyle and go and see my doctor and my dentist, as some of my pain may be down to a tooth, I broke thirty years ago. It hadn’t given me much trouble until the stroke.
One modification I have made is to make the house cooler. This seems to have improved the flu-like symptoms, but my feet are now colder. And I’ve never ever worn slippers and won’t start now!
So it’ll be interesting to see how things work out.
One question though, is what is the best time to take Warfarin? I ask this as I normally take it about six in the evening and the itch seemed to get bad after I took it yesterday.
INR by Handheld Monitor
I had my first experience of this tonight and it worked well and took just a couple of minutes.
Some health professionals have said to me before that they don’t like the system, but as a patient it’s certainly less stressful than giving a blood sample. Or it certainly was for me.
My INR had hardly changed but the software used with the monitor, gave me a much more complicated schedule of Warfarin doses, than I used to get in Suffolk. Could it be that in Suffolk, the anti-coagulant team simplified the schedule, so that less patients got confused?
I won’t comment on all this from a medical point of view, but given a choice I would take the monitor route, as I got my result there and then and I suffered little or no discomfort.
But speaking as a trained control engineer and a competent software engineer, the software that works with the monitor, may be something that could be improved to make Warfarin regimes less complicated or prone to error.
A Replacement for Warfarin?
On BBC Breakfast this morning, they were talking about a replacement for Warfarin, that would be just one pill a day.
For a lot of people, this will obviously be better and it is likely that the cost to the NHS will be less in terms of blood testing. But this new drug will not be cheap.
In a way, I think that the alternative of providing an up-to-date National Anticoagulant Service might be much better.
As an example, I’m moving to London in a few weeks, so I’ll have to get that sorted fairly quickly. But as I usually have to be tested every two weeks or so, I can envisage a few small problems, especially as I’ll be needed to be tested over Christmas.
One In and One Out!
I had a bone density scan some weeks ago and as I’ve not heard anything, I asked the nurse to see if there was anything on their computer, when she did my Warfarin blood test and gave me a shot of B12 today.
There wasn’t any news and judging by how I feel, my bones may not be tip-top, but they certainly aren’t in falling apart mode, as I would have hoped that I would have been called in for the bad news.
It strikes me that there could be a big increase in efficiency here, with possible cost savings!
If you have a test that can be quantified accurately and you are well on the right side of the problem level, surely, you can be told the results either by a more or less standard e-mail and/or letter.
With my bone scan, it might say that I’m reasonably fine, but I should come back for another scan in say six months. A copy could also go to my GP, so she would know as well. I have a feeling, that a lot of communications from hospitals to GPs are actually letters not e-mails and are scanned in the surgery. If I’m wrong, which I hope I am, about these letters please correct me!
There must be hundreds of instances in the NHS, where a sensible bit of automation could save money and redeploy staff to more important duties, than writing lots of similar letters.
We are seeing instances of automation, like appointments systems that text you reminders, but we need to see more. I personally would like to see a better system for anti-coagulant testing.
The Anonymous Widower 