Anticoagulation Management After Bridging

[Martin1962]

So 10 months after having my mitral valve replaced with a mechanical one, I have just had my first experience of bridging with injections for a colonoscopy and polyp removal. Glad to say that the polyps were found to be benign, but the whole bridging process was a bit of a nightmare. Instructions from the hospital regarding injections and starting up warfarin again afterwards were pretty poor and not well co-ordinated with my local GP's office who normally oversee my INR. I'm in the UK and have recently started home testing, which has made things a bit easier. My range is 2.5-3.5. The hospital provided only six injections, two of which had to be used before the procedure. Apart from the hassle of running around between the hospital and GP to get more injections, the real problem for me has been the time (2.5 weeks!) to get back into range.

I'm going to need further procedures in the future that will necessitate bridging, and am keen to make the process a lot easier next time. I will liaise more closely with my local GP, but would be interested to hear of other people's experiences with bridging:

Did it take you a long time to get back into range after the procedure?
Were you told to take a higher dose of warfarin for a few days after the procedure to get back into range more quickly?
Did your warfarin dosage go back to what it was before the procedure? (My dosage was gradually increased from 38mg per week to 45mg and I'm still on that higher dosage now so am expecting my INR to increase further over the next few days).
Were you instructed to continue injections until your INR is back in range, or close to your range (say over 2 if your range is 2.5-3.5)?

Thanks, and apologies for the lengthy post!

 

[pellicle]

Hi

Here is what I did

https://cjeastwd.blogspot.com/2017/12/perioperative-management-of-inr.html
and here is my write-up of @Chuck C did to extend that
https://cjeastwd.blogspot.com/2022/05/rapid-dust-off-inr-management.html
If you are self testing (and better, self managing) then have a read through those and hit back with questions.

Best wishes

 

[carolinemc]

So 10 months after having my mitral valve replaced with a mechanical one, I have just had my first experience of bridging with injections for a colonoscopy and polyp removal. Glad to say that the polyps were found to be benign, but the whole bridging process was a bit of a nightmare. Instructions from the hospital regarding injections and starting up warfarin again afterwards were pretty poor and not well co-ordinated with my local GP's office who normally oversee my INR. I'm in the UK and have recently started home testing, which has made things a bit easier. My range is 2.5-3.5. The hospital provided only six injections, two of which had to be used before the procedure. Apart from the hassle of running around between the hospital and GP to get more injections, the real problem for me has been the time (2.5 weeks!) to get back into range.

I'm going to need further procedures in the future that will necessitate bridging, and am keen to make the process a lot easier next time. I will liaise more closely with my local GP, but would be interested to hear of other people's experiences with bridging:

Did it take you a long time to get back into range after the procedure?
Were you told to take a higher dose of warfarin for a few days after the procedure to get back into range more quickly?
Did your warfarin dosage go back to what it was before the procedure? (My dosage was gradually increased from 38mg per week to 45mg and I'm still on that higher dosage now so am expecting my INR to increase further over the next few days).
Were you instructed to continue injections until your INR is back in range, or close to your range (say over 2 if your range is 2.5-3.5)?

Thanks, and apologies for the lengthy post!

It depends on the procedure, some you will not have to bridge for and others you will. Usually the lab will decide when you get INR done. Just be patient when it happens, they do not make you wait too long. I had mine done two weeks after bridging for cataract surgery, Was 2.5.

 

[Martin1962]

It depends on the procedure, some you will not have to bridge for and others you will. Usually the lab will decide when you get INR done. Just be patient when it happens, they do not make you wait too long. I had mine done two weeks after bridging for cataract surgery, Was 2.5.​ So did you bridge every day for 2 weeks before your INR was tested? The issue I had was that the hospital provided only 6 injections, I ended up needing 20 daily injections until my INR got back into range (home testing every few days). Not a pleasant experience. Unfortunately I'm going to have to go through it all again for a kidney stone removal and then possibly a pacemaker change next year, and am keen to make the process a lot easier next time.​

 

[pellicle]

I ended up needing 20 daily injections until my INR got back into range

pardon me, but if this implies you took 20 days to get in range then I'm sure my above blog posts will help.

 

[Beach77]

It took me about 7 to 14 days after my colonoscopy w/ polyps removed to get to my range (2.5 to 3). The clinic started slowly upping my dose, I wasn't happy with their slowness. Once I got to a certain level I stopped the shots and we just worked on getting my levels up. It seemed like it took forever. I did go back to my same dose eventually. (9 mg daily w/ 10 mg one day)

 

[Martin1962]

pardon me, but if this implies you took 20 days to get in range then I'm sure my above blog posts will help.

Correct. I stopped my warfarin on Sat 5th Nov and started again on the evening of my procedure on Wednesday 9th. I started the injections on Monday 7th and continued as instructed every day until Sunday 27th Nov when my INR finally came back into range. Before the procedure my INR had been in range for several months at around 2.5-3. On the day of my procedure it had dropped to 1.3. So far so good, but it continued to drop to 1.1 on Friday 11th and only after that very slowly started to go up until it finally got into range at 2.6 on Monday 28th. During that time my warfarin dose was gradually increased from 38mg per week to 45mg per week. My INR is still going up, 3.2 yesterday, so after a consultation with my doctor we agreed to drop the dose to 42mg and test again in a week. The algorithm on their system would have kept me on the same dose, which I'm sure would have resulted in my INR going above range.

Thanks for the links to your blog post. I need to read in more detail and digest to see if it helps with my situation for next time. The main problem for me seems to have been the length of time it took to get back into range after the procedure, and the ultra conservative approach of my doctors insisting I inject every day until I got back into range. I would have thought I could have stopped the injections at least a week earlier when my INR had got above 2. Next time I will certainly be liaising more closely with my local GP and raising these concerns.

 

[Martin1962]

It took me about 7 to 14 days after my colonoscopy w/ polyps removed to get to my range (2.5 to 3). The clinic started slowly upping my dose, I wasn't happy with their slowness. Once I got to a certain level I stopped the shots and we just worked on getting my levels up. It seemed like it took forever. I did go back to my same dose eventually. (9 mg daily w/ 10 mg one day)

Thanks Beach77. Similar to me but as per my reply to pellicle it took me even longer to get back into range, injecting the whole time. I too hope eventually to get back to my pre-procedure dose.

 

[pellicle]

Hi

well, you do seem to have a conservative crowd in that team.

Correct. I stopped my warfarin on Sat 5th Nov and started again on the evening of my procedure on Wednesday 9th.

ok ... so you restarted on the evening of the 9th and your procedure was on the 9th ...

I started the injections on Monday 7th and continued as instructed every day until Sunday 27th Nov when my INR finally came back into range.

jaw dropping

On the day of my procedure it had dropped to 1.3.

that's pretty perfect, but the mistake was not following up with a bolus ... now normally I'd say that "weekly dose" counting is moronic and brings nothing but smoke and mirrors to the table, that you're in the UK would make that even more mysterious because I'd understood that the UK used a more scientific medical approach of daily dose. Why pick weekly? Because your body doesn't run on a calendar?

However as you do know that you take around 45mg a week (thats about 6.5mg a day) and you'd be able to use that to calculate your bolus dose. You're missing 2 days worth so that should be what you'd start with, which would be the missing 12mg added to the 6something you normally take daily (and maybe a bit more than usual the next day too). Then measure INR daily (as per my blog post) or half daily (as @Chuck C did in his variant) and guide gently but firmly. Keep a steady hand on the tiller as they say.

So far so good, but it continued to drop to 1.1 on Friday 11th and only after that very slowly started to go up until it finally got into range at 2.6 on Monday 28th.

well of course it did ... the drug works by interference in a mechanism, so it needs to re-establish interference with that mechanism again (having been washed out) and so that complicates things ... think of it as priming a pipeline. This is a bit above pharmacokinetics 101, but not much (and yes, I did a Biochem degree).

During that time my warfarin dose was gradually increased from 38mg per week to 45mg per week. My INR is still going up, 3.2 yesterday, so after a consultation with my doctor we agreed to drop the dose to 42mg and test again in a week.

classic ... and they overshot too ... can you tell me please what your daily dose normally is?

The algorithm on their system would have kept me on the same dose, which I'm sure would have resulted in my INR going above range.

agreed

Thanks for the links to your blog post.

welcome

I need to read in more detail and digest

ask questions, pay attention to what the graphs suggest, I don't know your background but I have found interpretation of graphs unexpectedly poor in the general public

The main problem for me seems to have been the length of time it took to get back into range after the procedure,

agreed

and the ultra conservative approach of my doctors insisting I inject every day until I got back into range.

and indeed after you were in range

I would have thought I could have stopped the injections at least a week earlier when my INR had got above 2.

exactly ... my advice is -> change doctor <-


Best Wishes

 

[Martin1962]

ok ... so you restarted on the evening of the 9th and your procedure was on the 9th ...

Yes, my procedure was on the morning of the 9th and I restarted warfarin in the evening as instructed by the hospital.

that's pretty perfect, but the mistake was not following up with a bolus ... now normally I'd say that "weekly dose" counting is moronic and brings nothing but smoke and mirrors to the table, that you're in the UK would make that even more mysterious because I'd understood that the UK used a more scientific medical approach of daily dose. Why pick weekly? Because your body doesn't run on a calendar?

Nobody mentioned taking a larger dose or "bolus" on the day or two after my procedure. Sorry, that's me using weekly dose, I thought it would be more concise to convey my dosage in that way rather than giving the daily dosages. My body doesn't run on a calendar but my weekly testing regime and dosing schedule does.

My usual dose before the procedure was 38mg per week split 6mg Mon, Thurs & Sat and 5mg the other days. This was the dose I was instructed to re-commence on the evening of the 9th. It wasn't increased until 17th Nov when it went up to 44mg per week split 7mg on Sunday & Wednesday and 6mg the other days. On 24th Nov it was increased slightly to 45mg per week split 7mg on Fri, Sun & Tue and 6mg the other days. My INR finally came into range on 28th Nov and my dose was decreased on 1st Dec to 42mg per week, unsurprisingly split 6mg each day.

exactly ... my advice is -> change doctor <-

Not so easy in the UK, you basically have the choice of working within the constraints of the NHS or paying a lot extra to go private. I'm with the NHS and to be fair they've been pretty good, it's just the post procedure INR management that has gone awry this time, and that seems to have been mainly the fault of the hospital team who carried out the procedure.

Thanks again for your help, a lot of useful information which I can use to discuss with my doctor and hopefully agree a much better process the next time I have to bridge for a procedure.

 

[carolinemc]

​ So did you bridge every day for 2 weeks before your INR was tested? The issue I had was that the hospital provided only 6 injections, I ended up needing 20 daily injections until my INR got back into range (home testing every few days). Not a pleasant experience. Unfortunately I'm going to have to go through it all again for a kidney stone removal and then possibly a pacemaker change next year, and am keen to make the process a lot easier next time.​

I have been tested in lab since 2001 Bypass surgery and replaced aortic valve with St. Jude's valve. Bridge is defendant on the procedure. Bridge for 1 1/2 weeks. Had no problems since after bridge, was back on warfarin and tested well then. Hopefully this time around, it will be easier. I even had extra this time.

 

[pellicle]

My body doesn't run on a calendar but my weekly testing regime and dosing schedule does.

OK, so if you took 43mg on Monday and tested the subsequent Saturday would that be a proper reflection of your INR?
Would alternative doses of 7.5 and 5mg provide stability?

Does this clarify why I prefer to work with Daily Dose?
I submit this argument
https://cjeastwd.blogspot.com/2014/05/inr-management-goldilocks-dose.html
Best wishes

 

[Astro]

Some of you have been having a rough time. All that painful bridging.

What would I do? For the first two days take about 150% of my normal dose (if the usual is 6mg, take 9 or 10mg for two days) then check my INR and fine tune from there. It is so much easier when you have the keys for the warfarin car.
I find a 150% catch-up dose useful on the odd occasional when I miss a warfarin dose (I have such a set routine for taking my medications but still can occasionally stuff it up).

 

[pellicle]

It is so much easier when you have the keys for the warfarin car.

100% ... I wouldn't do it any other way.
Wild Horses couldn't drag me back to a clinic