Bridging to Lovenox - first time

[ctyguy]

OK....My poor little tooth where I lost the crown is kaput. Its cracked and can't be saved. The dentist wants to pull the tooth and do a bone graft that will allow a dental implant down the road.

In order to do this they want me off Coumadin for 3 days and then Lovenox and Coumadin for a few days until my INR comes back up. The procedure is scheduled for Friday so I would need to start skipping doses tonight. Im not all that concerned with it, sounds like I will have a few days of potential risk but it seems relatively low. Its my understanding that Lovenox is fast acting and I would take that while ramping back up on Coumadin.

I know folks have had different experiences on this, just looking for opinions from the experts.

Thoughts ? Opinions ?

 

[ctyguy]

just got off the phone with the dentist. my cardio has recommended that I cut my dose in half for the next 3 days. My INR was 2.3 on Friday so assuming Im still at 2.3 Im guessing my INR should be in the 1.5 range by Friday. No bridging to Lovenox. Just ramp my dose back up after the appointment. Bleeding should be nominal based on what they are going to do.

Does this sound reasonable ?

 

[Ross]

There really isn't any reason to come off of Coumadin for this. I know, I know, I tried to talk sense into them too to no avail. My lesson learned. Bridge until 12 -16 hours before surgery, then if your still seeping blood afterwards, forget the Lovenox and simply start your Coumadin back up. If there is no bleeding, which there shouldn't be, then start Lovenox and Coumadin together and continue the Lovenox until your at least 2.0.

 

[Ross]

Guess we just passed each other. YES that sounds total realistic and reasonable. Wish mine would have learned something.

 

[ctyguy]

Just heard now from the Coumadin Clinic I go to. They have NO experience with On-X valvers so they have been calling all over the place looking for recommendations. What is interesting is they went to the Cleveland Clinic website looking for a number for Dr Petterson (my surgeon). The number listed was his cell phone and amazingly he answered. She asked him his opinion about me being off Coumadin for 3 days and should I bridge with Lovenox post procedure. She said he paused and said its iffy and that I should be able to just restart Coumadin. He then said to bridge me just to be safe. She didn't ask him about 1/2 dosing for the next 3 days but considering he was on the fence of me bridging to begin with Im pretty confident that the 1/2 dose strategy should work out fine. Once Im through the procedure I'm supposed to take 8mg for Fri, Sat, Sun and then back to my normal 6 on Monday. I also made an appt at the clinic on Monday afternoon to have my INR checked.

Who would think you have to get a PCP, a cardiologist, AND a world class surgeon on the phone for something so trivial as an extraction !!

 

[Ross]

And again, there is absolutely no need to come off of it in the first place. These people will never learn.

http://www.valvereplacement.com/forums/attachment.php?attachmentid=6310&d=1223065492

 

[Lynlw]

And again, there is absolutely no need to come off of it in the first place. These people will never learn.

http://www.valvereplacement.com/forums/attachment.php?attachmentid=6310&d=1223065492

Ross, would the fact they are also doing a bone graft and not just pulling his tooth make a difference? I'm not sure what all that involves, where they get the bone to graft from ect, but it sounds more complicated

 

[Ross]

It may, but they'd have to really open his mouth up big time to cause enough bleeding to warrant coming off of Coumadin. The Dental Surgery PDF tries, just like I do, in vain, to get it through these Doctors minds that just about all they've been doing is based on MYTH.

Conclusions. Serious embolic complications,
including death, were three times more likely
to occur in patients whose anticoagulant therapy was
interrupted than were bleeding complications in
patients whose anticoagulant therapy was continued
(and whose anticoagulation levels were within or
below therapeutic levels). Interrupting therapeutic
levels of continuous anticoagulation for dental
surgery is not based on scientific fact, but seems to
be based on its own mythology.


Clinical Implications. Dentists
should recommend that therapeutic levels of anticoagulation
be continued for patients undergoing
dental surgery. Practitioners should consult with the
patient’s physician if necessary to determine his or
her level of anticoagulation before performing dental
surgery.

 

[Bina]

I have actually had more nose bleeds, etc. previously while I was taking 81mg Aspirin in conjunction with my Coumadin.

 

[ctyguy]

My understanding of the bone grafting is that its not particulalry difficult. Once the tooth is pulled they will clean the space out to ensure there is no infection. At that point they will use cadaver bone (ground up) and basically pack it in the hole, place a peice of material over the top and then throw a stitch or two on top. This foreign material is recognized and used as a building block for the native bone to grow over it and basically absorb the material. The intent is to not lose bone mass which once healed can be used as a base for the dental implant.

I have to be honest that given all the hubub about this Im a bit nervous for tomorrow. Im sure it will be fine but Im still a bit nervous now.

 

[Ross]

You are still going to bridge correct?

 

[ctyguy]

actually no. I cut my coumadin in half last night and again tonight. When my INR was checked last Friday I was at 2.1 so I suspect by tomorrow morning I will be in the 1.5 range. Once Im home after the procedure tomorrow Im going to take 1.5X my normal for the next 3 days and then get my INR checked on Monday afternoon at the clinic.

 

[Ross]

That's right, sorry. I have so much going on with myself that I'm forgetting whats going on with you folks.

You should be FINE. I wished my dental surgeons would have listened and done likewise, but no, they had to play the bridging game and I had some major bleeding because of LOVENOX, not because of Coumadin.

 

[ctyguy]

what you had done was WAAAAAY more complex than mine. Im dealing with one molar, if memory serves correctly you were dealing with all your teeth being yanked at once right ?

 

[Ross]

what you had done was WAAAAAY more complex than mine. Im dealing with one molar, if memory serves correctly you were dealing with all your teeth being yanked at once right ?

Yes sir and 2 of those extractions involved major infections requiring they go down even deeper then normal to get all the infection.

 

[Lynlw]

My understanding of the bone grafting is that its not particulalry difficult. Once the tooth is pulled they will clean the space out to ensure there is no infection. At that point they will use cadaver bone (ground up) and basically pack it in the hole, place a peice of material over the top and then throw a stitch or two on top. This foreign material is recognized and used as a building block for the native bone to grow over it and basically absorb the material. The intent is to not lose bone mass which once healed can be used as a base for the dental implant.

I have to be honest that given all the hubub about this Im a bit nervous for tomorrow. Im sure it will be fine but Im still a bit nervous now.

OK thanks for the explaination., Makes sense. I thought they were cutting out a small piece of bone from somehwere else on you

 

[ALCapshaw2]

I'm late reading this thread but...

since you have an On-X Valve and mentioned that "they Called Everywhere" trying to find out what to do for you,

Did anyone call On-X? (888-339-8000)

They just may have some useful ideas since they are conducting NO and LOW Anti-Coagulation Studies on their valves.

Just a thought...

'AL C'

 

[ctyguy]

Al...thanks for that number. Im going to give them a quick buzz in the AM. I will post back what info they give me.

 

[ctyguy]

The saga continues....I had my procedure today and it went off without a hitch. Minimal bleeding, actually the dentist said it was less than what he would normally see. The worst part of it is the 5 or 6 needles in the mouth.

My cardio's office called me a few hours ago and they have decided that I DO need to bridge to Lovenox after all ! So starting tonight and for the next 3 nights I get to give myself a nice needle in the belly. Probably not a big deal but when the told me I had to give to myself in the belly I had vision of the movie Pulp Fiction.

My question now is there anyone out there who has ever heard of an allergic reaction to Lovenox ? I've never taken it before and would like a little re-assurance before I poke myself. I've also taken my coumadin dose for the day too.

And one more thing....I don't like Lovenox already ! $190.00 for 3 doses !!!

 

[Bina]

I am hyper sensitive to most everything and the one and only Lovenox needle that I had 4 yrs ago was really nothing at all.
My nurse daughter volunteered, and she totally enjoyed sticking me.