Bridging after biopsy

[Eva]

Edited after posting: my cardio just responded that I need to take my warfarin too. So just disregard this post. Thank you.

I am a bit confused between my cardio’s instructions and the information I found online regarding post-procedure bridging.
I’m taking my lovenox injections. Should I restart warfarin too with lovenox injection?. For how long did you bridge after your procedures?

My cardio’s instructions:
“1 day after the procedure is completed, restart lovenox twice daily until your INR is back above 2.5 at goal after which you can then continue the coumadin solo as before and discontinue the lovenox. “ There’s no mention if I should start warfarin too at the same time.

Online instructions:
healthonline:
“Bridging will be started again after your procedure or surgery, when it is safe. It will be continued for 5 to 7 days while you also take warfarin.”

heart.org:
“Post-procedure considerations:
i. Resume warfarin within 24 hours (the evening of or the following day) after procedure and when there is adequate hemostasis
ii. Resume parenteral anticoagulation 24 hours after procedure for low bleed risk”

Thanks in advance.

 

[MdaPA]

My cardio’s instructions:
“1 day after the procedure is completed, restart lovenox twice daily until your INR is back above 2.5 at goal after which you can then continue the coumadin solo as before and discontinue the lovenox. “ There’s no mention if I should start warfarin too at the same time.

Agree it's not spelled out in your cardio's instructions to restart warfarin, but it's "implied" since it says "until your INR is back above 2.5 at goal". Lovenox does not affect your INR.

Did you confirm what time the next day (i.e. AM or PM) when to restart warfarin (usually it's the same time of day prior to bridging) and what the dosing is?

What are your pre-op bridging instructions? Were you instructed to get your INR down to 1.0 the day of the procedure?

 

[pellicle]

@Eva
this:

Agree it's not spelled out in your cardio's instructions to restart warfarin, but it's "implied" since it says "until your INR is back above 2.5 at goal". Lovenox does not affect your INR.

 

[Eva]

Thank you @MdaPA & @pellicle. I thought so too, but wasn’t sure. Luckily, he messaged me back quickly last night confirming taking it!

 

[Eva]

Did you confirm what time the next day (i.e. AM or PM) when to restart warfarin (usually it's the same time of day prior to bridging) and what the dosing is?

What are your pre-op bridging instructions? Were you instructed to get your INR down to 1.0 the day of the procedure?

Thank you.
INR was 1.0 on the day of the procedure. It is still 1.0. I restarted warfarin regular dose I was on before (5.75 mg) last night.

His instructions were for the first biopsy:
“
* hold warfarin 4 days before the procedure (and hold coumadin until at least 1 day after the procedure completed assuming no complications) and then
* start the lovenox injections (80mg twice a day (morning and evening)) 2 days before the procedure as a bridge and then
* hold lovenox 1 day before the procedure. Then
* 1 day after the procedure is completed, restart lovenox twice daily until your INR is back above 2.5 at goal after which you can then
* continue the coumadin solo as before and discontinue the lovenox. ”

 

[pellicle]

Hi Eva

INR was 1.0 on the day of the procedure. It is still 1.0. I restarted warfarin regular dose I was on before (5.75 mg) last night.

just food for thought but I've put together two models of getting your INR in range, the top one is the standard approach of just resume your dose, the bottom one is what is called in medical circles "a bolus administration"

in the standard strategy you don't get to the right warfarin serum levels for about 5 days, while in the second you get there within 3. Once your accumulation of warfarin is in the right area your body will be forced into an INR of closer to your normal range faster.

This may save you 2 or 3 days (perhaps more) of being on lovenox.

Remember, in this case we already know your previous dose, we are not starting you on warfarin with no know levels.

IMPORTANT point, I assumed that your normal dose was 5.75mg daily. Also, this is a simple model and there may be other lags involved (as I found out when I went down to INR = 1

For instance this is measurements (in the bar graph) and model (in the lines)

my procedure was on the first Wednesday, I have no logical reason why I took a half dose on the Sat except to say that probably I didn't see a drop from 2.4 fast enough. I know from subsequent experiments that it takes less time to go up to range if you don't hit rock bottom.

In my case I only needed to be INR < 1.4 to make the gastro happy. Even with a bolus administration it took me 7 days to be above INR 2.0

HTH

 

[Eva]

Thank you very much @pellicle,

Yes, this is very helpful. I’ll be happier to reduce the days of Lovenox injections. So, I took 10 mg tonight.
Thanks again. I’ll keep you informed and will save your recommendation for next time (which unfortunately might be soon)!

 

[pellicle]

Thank you very much @pellicle,

Yes, this is very helpful. I’ll be happier to reduce the days of Lovenox injections. So, I took 10 mg tonight.
Thanks again. I’ll keep you informed and will save your recommendation for next time (which unfortunately might be soon)!

happy it helps.

I'll be keen to follow your INR progress.

Best Wishes

 

[Eva]

happy it helps.

I'll be keen to follow your INR progress.

Best Wishes

Had taken
10 mg on Monday night …. Tues. morning: INR 1.2
7.5 mg on Tuesday night … Wed. morning: INR: 1.4
6.75 yesterday/Wednesday …Thurs. morning INR: 1.6

Will keep you posted. Wish I started higher dose earlier. These lovenox shots are not fun!

 

[Protimenow]

Lovenox is certainly NOT any fun. I stopped bridging a few years ago, knowing that my INR would be back up in a few days after a procedure.

FWIW - if a procedure has a high risk of clots forming - even after a day or two (and they'll probably keep me as an inpatient and on IV heparin to reduce the risk), I may consider Lovenox - although, as you said, it is NO fun.

 

[pellicle]

Will keep you posted. Wish I started higher dose earlier.

Yeah, I get that.

These lovenox short are not fun!

 

[pellicle]

Oh ... and

6.75 yesterday/Wednesday …Thurs. morning INR: 1.6

at this point its important to resume to keep your regular dose to prevent overshoot .. a little bit is quite likely, but I prefer to not hit the upper limit or go over it (played too much lunar lander as a lad , or was it "not enough")