Bridging with Lovenox

[mecretired]

Advice, please. What am I doing wrong? I’m in the middle of my second time bridging with Lovenox. I pinch skin/fat on my abdomen (2inches from navel and alternate sides) slowly inject, count to about 5 seconds and withdraw needle. All appears to be ok(other than hurting for 10-39 min) then some hours later I get a bruise from a nickel size to a silver dollar size. Then anywhere from 3-12 hours later I start to bleed from the injection site. One night I injected at 8pm and went to bed about 10pm. I woke in the morning and had bless thru the bandaid, thru my sleep shirt and into my sheet and mattress pad. This wasn’t enough blood to be concerned about but definitely annoying. The last time I bridged was 6 years ago. I had the bruising but no bleeding. Suggestions?

 

[pellicle]

I'm not sure you're doing anything wrong, but heparin is an anticoaguant and so, it stops coagulation. So wounds can ooze or bleed.

I recommend you carefully read this article (which underpins my no-bridging approach)

https://www.nps.org.au/australian-p...e-perioperative-management-of-anticoagulation

Do the benefits of anticoagulation outweigh the risks?​

The approach to the management of anticoagulation in patients with prosthetic valves undergoing non-cardiac surgery remains controversial. The need for perioperative anticoagulation in patients with mechanical heart valves has been questioned in a recent review. The authors argue that for every 10 000 patients with mechanical heart valves who are given perioperative intravenous heparin, three thromboembolic events are prevented at the cost of 300 major postoperative bleeding episodes.3 These figures are calculated by assuming an average thromboembolic rate of 8% per year in patients with mechanical heart valves, an anticoagulation-free period of four days and a 3% risk of major postoperative bleeding with intravenous heparin. In light of these calculations, a risk-benefit analysis would preclude the use of full dose anticoagulation during the perioperative period in patients with mechanical valves, except in patients with very recent arterial embolism who have a high risk of recurrence in the absence of anticoagulation. In the absence of recent embolism, the authors recommend, for hospitalised patients, the use of subcutaneous low dose unfractionated or low molecular weight heparin at doses used for prophylaxis against venous thromboembolism, with no prophylaxis for outpatients.​

​

There are limited prospective data to support or contradict these recommendations.​

[underline mine]

It is not the only such article of its type, you can search for more.

What is your INR now?

I posit that if your INR is greater than 1.5 that you consider

• getting your INR up to usual range pronto
• not continuing heparin

one of the benefits of my method is it assists you in learning how to tailor a bolus administration of warfarin to suit your metabolism.

I hope the ooze subsides.

 

[mecretired]

Thanks. The bridging was for a colonoscopy. The doctor said he could do the colonoscopy while on warfarin but would not remove any polyps. Turns out I did have multiple polyps—2of which need surgery. One was large enough he couldn’t get it—but didn’t “think” it was cancer. Another polyp was a flat one-probably not cancer but precancerous. So i am waiting for biopsy results and appointment with surgeon. Gastroenterologist says small part of colon would have to go but they would resection and I shouldn’t have any problems. My regular dose of 7 mg warfarin last taken on Wednesday. Started Lovenox on Saturday am per cardio instructions. INR on Sunday was 1.3 soI’m sure it’s lower today. Colonoscopy today. Back on loading dose of 10mg starting tonight along with 2xday Lovenox until back in range. Not sure what the protocol is for the surgery.

 

[tom in MO]

Sorry to read about your difficulties. I don't know squat about bridging so anything I'd say about it would be worthless. Good luck with your colonoscopy today.

 

[Protimenow]

I'm getting my pacemaker replaced with a CRT-D (biventricular, with defibrillator) tomorrow, and I've convinced my surgeon that I don't want to bridge (although my INR is being reduced). He respects this request.

After I get home tomorrow, I will restart my normal dose and should have my INR back in range in about three days.

I've bridged in the past, but probably didn't need to, As long as my INR is low enough for the procedure, and I can start taking warfarin right away, I don't worry about bridging.

FWIW -- my first pacemaker was inserted three years ago when I was fully anticoagulated and didn't seem to be an issue for my doctor.

 

[mecretired]

I would have liked to see a compromise where I would not have to bridge but the gastroenterologist was firm that he would not be able to remove any polyps if I were not off warfarin. And—my cardiologist insisted that I needed to bridge with Lovenox. Six years ago I had lung surgery and didn’t bridge. Had a LOT of bleeding after surgery and came close to going back into surgery to stop the bleeding. So not sure what the answer is. Hate bridging but if your doctors insist??

 

[Protimenow]

If the doctor will instruct you to start back on Warfarin right after the procedure, I would consider the low possibility of a clot forming on your valve.

I don't bridge. I'll only bridge if they want me to KEEP my INR low for some reason (but if this was happening, I'd probably be in the hospital, getting IV heparin). For me, I don't consider any risk for being below 2.0 for a week or less.

 

[pellicle]

I would have liked to see a compromise where I would not have to bridge but the gastroenterologist was firm that he would not be able to remove any polyps if I were not off warfarin.

interestingly mine was totally fine with me being INR 1.4 or less ... I brought my Coaguchek in with me to test in case she wanted to see. She was fine with my word. Some polyps were removed, they were benign.

Meanwhile I was quite twitchy about a bleed because a friend who was not on warfarin at all nearly died because they punctured his bowel when doing the snip. He went on to needing surgery and a resection.

So I guess it depends on the practitioner. The lady I use was recommended to me by friends (I'm fortunate to know people who are; pharmacists, doctors, other medical specialists).

 

[pellicle]

If the doctor will instruct you to start back on Warfarin right after the procedure, I would consider the low possibility of a clot forming on your valve.

just to be clear, you weren't saying "I would consider the possibility of a clot forming on your valve low" were you?

For general discussion: personally I'd say the chances of a thrombosis forming on the valve nil in that period. The possibility of a blood stream thrombosis that led somewhere and got stuck a bit higher though; but still not high by any means. Unless you already have a stroke / thrombosis history.

 

[mecretired]

My opinion— I would love to go off warfarin just long enough to bring my INR to a number the endocrinologist could work with. Prior to the colonoscopy I couldn’t get him to give me a number. He told me I had to talk with my cardiologist. She said to bridge. I did 3 days without warfarin and my inr was 1.3. It was 2 more days before procedure.

 

[pellicle]

I did 3 days without warfarin and my inr was 1.3. It was 2 more days before procedure.

so, you now know you could have done less days without warfarin next time.

A worthy experiment

 

[Protimenow]

just to be clear, you weren't saying "I would consider the possibility of a clot forming on your valve low" were you?

For general discussion: personally I'd say the chances of a thrombosis forming on the valve nil in that period. The possibility of a blood stream thrombosis that led somewhere and got stuck a bit higher though; but still not high by any means. Unless you already have a stroke / thrombosis history.

Thanks for pointing out that I didn't complete my sentence.

I consider the probability of a clot forming on a valve after just a few days anticoagulated to be very low.

I'm putting my money where my mouth is in less than eight hours -- I'm having a pacemaker implanted. My INR will be around 1.4 or so and I'll restart my warfarin when I get home (assuming, of course, that this simple procedure doesn't kill me).

 

[pellicle]

assuming, of course, that this simple procedure doesn't kill me

Best wishes for an uneventful procedure

 

[mecretired]

Thanks for pointing out that I didn't complete my sentence.

I consider the probability of a clot forming on a valve after just a few days anticoagulated to be very low.

I'm putting my money where my mouth is in less than eight hours -- I'm having a pacemaker implanted. My INR will be around 1.4 or so and I'll restart my warfarin when I get home (assuming, of course, that this simple procedure doesn't kill me).

Good luck with your surgery and let me know how it goes.

 

[carolinemc]

I would have liked to see a compromise where I would not have to bridge but the gastroenterologist was firm that he would not be able to remove any polyps if I were not off warfarin. And—my cardiologist insisted that I needed to bridge with Lovenox. Six years ago I had lung surgery and didn’t bridge. Had a LOT of bleeding after surgery and came close to going back into surgery to stop the bleeding. So not sure what the answer is. Hate bridging but if your doctors insist??

Yes they do for any major surgery or major procedure.

 

[Protimenow]

Thanks.

It WAS uneventful. I was sedated during much of the operation and able to get an idea of what was going on, but missed the interesting stuff (adjusting and fine tuning the device entirely).

I'm waiting for the antiobiotic that was ordered to arrive.

My INR two hours before the procedure was 1.4.

And of course I took a dose (1.5 X normal -- maybe a mistake) when I got home. In my case I saw no need to bridge.

I'll return to my usual daily dose tomorrow.

 

[pellicle]

Good to hear it was uneventful

(1.5 X normal -- maybe a mistake) when I got home. In my case I saw no need to bridge,

I don't think so, I took about that

and it still took longer to raise back up thatn I'd wanted. I also ceased a day earlier than I could have but in the scheme of things I felt

Chuck of course (having read my prior experience) used a more aggressive and well measured take with multiple measurements in a day

which averaged out (taking day by day averages) to this

Full details here:
https://cjeastwd.blogspot.com/2022/05/rapid-dust-off-inr-management.html