Maybe it's not just the painkillers. Your appetite may be different not that you're not taking as much pain killers. Regardless, I wouldn't worry about it too much. IF you're testing regularly, then they'll adjust your warfarin to accommodate your lower INR. I wouldn't be afraid to come off painkillers because of your INR.

I'm not meaning I'm afraid of coming off them, I want to stop taking them and gradually I am. It just bothers me that my INR is dropping so fast with it, I'm meant to be 3-3.5 area and last test told me 2.3...that's quite a way out of "therapeutic" range.

The nurse asked me about any diet changes, most notably increased intake of green veggies, which are Vit K rich, which I haven't done, if anything I've had a little less of them recently, but not a huge difference.

At 2.3 INR I'm not worried, it's the "regular" therapeutic level over here, point is though I can still reduce my PK intake by the same amount I have done already, meaning if it drops again by 0.7 I will hit 1.6 INR..which is kind of alarm bells moment if it's been like that for a period of time before I get tested...

My tests so far have been once a month and each coincide with a drop in my intake of PK's rather than any diet changes, they want me back in next week (shortened to two weeks) to see if my INR is stable at 2.3 or drops further still...

@stuart---I'm glad you're going to have your INR tested more often.

"Taking more than small occasional doses of paracetamol, or taking it for longer periods may raise your INR and cause the blood to become slower at clotting. This means you are at risk of bleeding. This is more likely to occur if paracetamol is taken in doses greater than 2 grams (4 tablets) daily for more than a few days."

http://www.nhs.uk/chq/pages/858.aspx?CategoryID=73&SubCategoryID=103

[my note---- and I'm not a doctor or nurse----- is this: You're correct---- if increasing PKs raises INR then taking fewer of them should have the opposite effect. Just my observation. ]

"Co-proxamol
NHS Direct states [1]:

The effects of warfarin may also be increased by dextropropoxyphene, which is in co-proxamol. There isnt much information available about this, and probably only a few people are affected. However, it isnt possible to predict who will be affected. If you take co-proxamol and warfarin together, your INR should be monitored carefully at the start.

The Northern and Yorkshire Regional Drug and Therapeutics Centre also highlights the problem of dextropropoxyphene [2], stating:

Dextropropoxyphene is particularly toxic in overdose. Death due to respiratory depression and heart failure can occur rapidly following ingestion of relatively small numbers of tablets particularly if taken with alcohol. In addition it may precipitate clinically significant drug interactions e.g. with warfarin. (NOTE: Our emphasis)"

http://www.tripanswers.org/answer.aspx?criteria=&tagtrail=/interactions/&qid=5284&src=0

(The above site cautions that the information is from 2006 so more recent information might want to be sought.)

Which I was doing...Like I said I was taking the max does (8 tablets, 4 grams) for quite a while and the pain in my chest was quite bad after starting warfarin treatment.

I've now reduced that amount to a maximum of 4 tablets or 2 grams a day, it is often less now. It coincides with my INR results being lower and lower as my intake of PKs gets lower and lower...I'm wondering if anyone else has had this happen or should I be thinking about something more?

I've totally had my INR go all over the place based on what I'm taking. Antibiotics, vitamins, painkillers, even eating a little bit less (I'm trying to lose weight.) Yeah, these meds can totally send your INR up or tank it, hard to tell which till you try them. I had two surgeries last year and managing my INR before and after those (with all the accompanying meds) has really taken a lot of time and effort on me and my doc's part. I've tested as often as every two days to try to keep an eye on things.

Do your INR management folks know that you're weaning of the PKs? They should be working closely with you to try to make sure you stay in range while this is going on. I would imagine that they're on board with you coming off them, but they need to be proactive to make sure your INR doesn't drop too far.

Even if you do drop out of range for a couple of days, you're really unlikely to clot in such a short time. I would focus more on keeping your INR in range than worrying about dropping too far. Insist on more frequent testing if you need to and make sure the nurse understands that the PKs DO affect your INR but that you want to come off and you need them to work WITH you to keep you in range.

Instead of just waiting to see if you keep dropping (which evidence points to), I would ask for a minor dose increase to offset the drop in PKs. Also, more frequent testing (once a month is NOT enough) until you get off the PKs entirely and your INR stabilizes.

Best of luck to you!

Stuart, we know what you're saying. What we're saying is that your doc or your INR manager should be managing your INR and warfarin through coming off the painkillers, testing more frequently if needed, changing your warfarin dosage etc.

Everyone reacts differently to meds. I have take antibiotics that are supposed to raise my INR and nothing happens. For others it sky rockets. There are things that make my INR go up high and go down low once in a while and I can't put my finger on why. It just happens sometimes. Just test more frequently for now and adjust your warfarin.

Well, I informed the nurse that I was taking less PKs...but I never really got anything said to me about it, I even phoned them after the appointment to make sure that it was known by the "phone team" (not sure what else to call it) as well.

Antibiotics raised my INR when I took them, I remember that, they wanted to drop my dose when I was tested and I told them not to because of the antibiotics, next test it normalized after the course was done.

As for a frequent test, I'm back in next Tuesday for a re-testing, which will be two weeks after the last one.

Thanks for your advice and words guys and girls. I don't mean to come across as ignorant to things that you have said, if I did I apologize for it. =)

I also mentioned...well asked if my weight loss may have caused something, seeing as I am 5-6 stones 30-35 kg or so lighter than I was back when I got diagnosed and they didn't say anything to that either.

Im from UK, I take paracetamol on and off, sometimes for a long period and max dose and it has made no difference to my INR. I am on warfarin for life, I also have testing of inr once a month but I also have my own inr machine so i can test myself if i feel i need to for my own reassurance.

How/where did you get hold of the self test machine? If you don't mind me asking you that is.

I really like having one, so i can test when i like and get results in minutes. I would only get one if your on warfarin for life. The one i use is by Roche, its a CoaguChek XS, you have to get the machine and then you get the strips, some PCT's let you have them on perscription, not where i live tho, so do your research, check if theres any deals as well as i paid 299 for mine and a few weeks later i could have got it for 199, you can pay monthly. Go direct to Roche phone 08081007666 or visit www.coaguchek.co.uk,

I could'nt get to coaguchek by clicking on it so type it into your computer. Hope this helps.

You just added an accidental comma to it is all =). Hmm, I'll speak to my GP then I guess...see what he says about it. It would certainly be better for me...

Update to this...Today I got tested again...INR down to 1.98....dropped yet again... 0.3 in 2 weeks....

Now the confusing part...according to the clinic nurse, painkillers like Paracetamol and Co-codamol DO NOT affect my INR, despite their own website saying that it DOES affect my INR....

I'm getting worried about how it's dropping so much...I was stable for a few months at 3.5-3.7 now suddenly it's rock bottomed... They now have me being tested Monday and again on Wednesday of next week, as well as a "bump" dose today and taking a slightly raised dose over all each day. up from 4.25mg to 4.5 mg daily....

My diet hasn't changed much at all really, but my weight, painkiller intake and exercise all have changed...despite me saying this to them..."it's not that, it must be your diet" is all I seem to be getting as a reply...

the painkillers i was given by the hospital were paracetamol and cocodamol - i was told that both were ok to take without having much effect on the warfarin - i shouldnt think it will be affecting your inr too much - its the most difficult thing to get to the correct level - i was on warfarin for 6 months and the longest i went without checks was 2 weeks as it was up and down and all over the place - normally it was lower and i had to increase my dose for a week, re test, it would be fine until the next re -test then it would be low again and so the circle continued. You might not think that you are changing your diet much but as you feel better you may be snacking more and eating larger portions at meal times, this can all have an affect too. I dont think its worth stressing about though - as long as you are tested regularly and follow the dr's advice re dosage you will be fine. good luck