Bridging with lovonox

[rnff2]

So it's been 8 months since I got my mechanical mitral valve and I now have to have my gallbladder out. I spoke with my cardiologist a few weeks ago and we discussed bridging my coumadin with lovonox and the sugeron who is doing my gallbladder surgery also discussed it when I met with him. Interesting enough when I called the cardiologist's office to let him know I have a surgery date and need him to set up my bridge his nurse informed me to stop my coumadin 4 days prior, test my INR daily and if I fall below 1.8 to call him. I told the nurse that I am not comfortable not bridging with lovonox and to tell the cardiologist this is not what we discussed. I finally did get him to order lovonox but now there is confusion because the prescription doesn't match the instructions the nurse provided when I talked with him. So on Monday I have to clarify the bridge instructions. Why can't this be simple?

Does any one with a mechanical mitral valve have experience with bridging??? Have any of you ever been told to just stop your coumadin and monitor your INR daily without bridging? I'm thinking it's because my cardiologist feels since I have an On-x valve I can run on the low side of my INR range, 2.5-3.5. But I'm not comfortable with 1.8 and no lovonox...am I wrong?

 

[pellicle]

Hi

yes, I have ... both times I had my debridement surgeries (quite a lot of scrape and hack involved) they did that. As I understand it the "new" way of thinking is that if you are a low stroke risk (which with a mechanical bileaflet you are) that they want you off warfarin prior to surgery because they require restoration of coagulation for the period just post surgery.

Then anticoagulation can be restored.

Lovenox (which is a heparin) is essentially an anticoagulant just as warfarin is, and so there would logically be on point in going off warfarin and onto another anticoagulant when (post surgery) coagulation is actually needed for healing.

My suspicion is that briding was done because then 1) they know what level of anticoagulation you are on (and often they didn't with people's poorly managed INRs) and 2) heparin is fast acting and fast to leave the system. So they can essentially remove your AC and restore it quickly.

I understand that in Australia this is now just as common a "perisurgical" management approach and that each has merits and issues.

The likelyhood of forming a thrbombosis obstruction in such a short time is insignificant and the key issue is stroke. IF you happened to be in hospital (which you would be) then stroke becomes less problematic as administration of tPA is likely to prevent any damage should the unlikely clot occur.

and yes, I was comfortable with it all.

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

http://www.uptodate.com/contents/perioperative-management-of-patients-receiving-anticoagulants

Best Wishes with the Gallbladder operation ... hope its all smooth

 

[Protimenow]

I have a 25 year old St. Jude Aortic valve. I've also had a few procedures (cardiac cath, minor sinus surgery), and I was told to discontinue warfarin a few days before the procedure. In theory, your INR can go as low as 1.0 without a problem - at that point, they'll use Lovenox to keep your anticoagulation high and keep you out of danger of stroke. Because Lovenox is fast acting, and relatively fast to leave your system, they can let your INR drop low before surgery, do the surgery, then bridge you while your warfarin dose kicks in.

TIAs usually take many days having an INR that is too low, to create a clot. If you're bridging during this period, you avoid that risk. The doctor's advice (and Pellicle's concurrence) seem sound.

I suspect that your gallbladder surgery will probably be through scopes, rather than a large incision, so the amount of bleeding should be fairly easy to control.

Good luck with your surgery.

 

[jeffp]

I'm a week and a half out from laparoscopic gallbladder removal and 10+ years post MVR with St. Jude's valve. Did fine with the gallbladder procedure. Only issue was constipation from the crappy food in the hospital. Pretty much same instructions, to stop 5 days before and call when INR get below 2. I tend to drop like a rock on missed doses, so I stopped 4 days before. In 2 days was down to 1.8 and went in for heparin preop. Stopped that 12 hours before surgery and started again 24 after surgey. As soon as INR above 2, I was out of there like a rocket. I hate hospitals. My cardio is not comfortable with Lovenox and suggested home IV for the heparin. I had no problem with that, but he insisted that they put in a PICC line for the home IV. I said "no way" and fortunately the day after our discussion the INR was acceptable. No negative sequelea after the gallbladder removal. One day of acidly stomach, achy shoulder from the cavity full of gas. I can eat (so far) anything I want, just in smaller quantities as if I get too full, it's tender.
As Protimenow said, good luck and do well.

 

[rnff2]

Thanks everyone. I feel like I can release some of my fears of developing a clot and being off my coumadin short term. I totally understand the medical thinking, but it's changes things when I'm the patient.

Yes, my surgery is scheduled as laproscopic and I'm supposed to go home the same day. So I hope they allow me to bridge at home and not hang in the hospital all weekend. I home test my INR so maybe that will help get me home too. I asked the nurse from my cardiologist's office about post op bridging and he said that was up to the sugeron, which seems strange, I would think the sugeron would say when to start and my cardiologist would take over the management.

My INR goes up and down fairly easily, usually I only need small tweeks to my dose and I'm right back in range. I'm hoping this continues to be my normal because I'm finding this coumadin thing is pretty simple when it comes down to it. (did I really say that? Lol)

Thanks again...I know now I won't stress so much about the whole coumadin and bridging stuff. Maybe I will stress about the surgery itself. Actually I'm looking forward to feeling better and not having abdominal pain almost every day.

 

[pellicle]

Hi

.... I totally understand the medical thinking, but it's changes things when I'm the patient.

indeed, personal involvement always changes things; a point I often make when I hear reports of "my surgeon said if it was him he'd totally do ..." is that "well when it actually IS him I am willing to bet he actually feels different when he's the patient."

Surgeons are even more control freak than nurses.

Maybe I will stress about the surgery itself. Actually I'm looking forward to feeling better and not having abdominal pain almost every day.

nah ... don't stress at all if you can avoid it (and glad to hear you're shaping up to management of warfarin with ease :- )

 

[marc_kowal]

I had to bridge for the very first time this past July. Here's the path to my post. http://www.valvereplacement.org/forums/forum/anti-coagulation/866252-bridging-for-the-first-time

Good luck with it.

~Marc

 

[rnff2]

Pellicle...I believe you knew I'd get over the "fear" of Coumadin. Lol. Thanks for all of you help and support. Its been a lot easier than I ever thought it would be.

Marc...thank you there is some great discussion on your link.

I saw the partner of my primary medical doctor today to get my medical clearance and he was fantastic. We reviewed the lovonox bridging for pre and post op. We discussed the issues I have been having with the nurse in my cardiologist's office and he fully supports my coumadin management. He also said I was right in insisting that I bridge because my valve is in the mitral position. We also discussed pre-op antibiotics and looked at the research behind not doing prophylactic antibiotics for gallbladder surgery, although he is supporting it because my cardiologist recommended it. He also feels I am doing the right thing by scheduling surgery now and not waiting for it to become an emergency.

I can say that was one of the most productive doctor appointments I have ever had. I'm so much more comfortable going into this and feel I'm making the right choice.

Thanks again everyone!

 

[marc_kowal]

This is a link as to how I gave myself the Lovenox shots. May prove helpful to some. http://www.valvereplacement.org/for...6617-giving-myself-my-first-lovenox-injection

 

[rnff2]

Thanks Marc...great information.

I'm a nurse so it's a mind over matter thing for me. I don't mind sticking others but it matters to me when I have to be stuck or stick myself. Lol.

My INR dropped from 3.0 to 2.0 after only missing 2 doses of Coumadin. I didn't think it would drop so quickly. Hopefully it goes back up just as quickly after surgery because these lovonox injections hurt/burn for quite awhile after the injection. Ouch!

 

[pellicle]

Hi

My INR dropped from 3.0 to 2.0 after only missing 2 doses of Coumadin. I didn't think it would drop so quickly. !

It does doesn't it imagine if you were using Acenocoumarol instead, which has an even shorter half life.

In the days before self testing this information would have not been available, it would have been much easier to just believe the unquestioned "rules of thumb" that simple minded people passed on to other simple minded people. People who just listen and accept, never seek evidence, or proofs.
Makes you question all those silly things you read about how your INR doesn't respond for a week and other myths.

Information is power, and liberation too my friend

 

[rnff2]

Hi


It does doesn't it imagine if you were using Acenocoumarol instead, which has an even shorter half life.

In the days before self testing this information would have not been available, it would have been much easier to just believe the unquestioned "rules of thumb" that simple minded people passed on to other simple minded people. People who just listen and accept, never seek evidence, or proofs.
Makes you question all those silly things you read about how your INR doesn't respond for a week and other myths.

Information is power, and liberation too my friend

I cannot imagine not having self testing and not knowing where I am within my range. Since I started this journey I can't understand why this isn't more routine. One would think the benefits of weekly home testing would decrease the complications that can arise from being out of range and in the long run save lives and money.

I am definitely thankful for information, and it is very liberating.

 

[Protimenow]

I cannot imagine not having self testing and not knowing where I am within my range. Since I started this journey I can't understand why this isn't more routine. One would think the benefits of weekly home testing would decrease the complications that can arise from being out of range and in the long run save lives and money.

I am definitely thankful for information, and it is very liberating.

I agree with you about weekly self-testing. I've been evangelizing about it for years.

There are a few reasons why weekly self-testing isn't more widely accepted:

The clinics that use protocols calling for monthly or even bi-monthly testing have a great success record. For patients who die or become incapacitated between tests, these patients simply 'drop out' of the program. I doubt that many anticoagulation clinics (or even research organizations who watch this stuff) ever question WHY people drop out of the program.

There was a time not too long ago when there were no readily available meters for self testing. Going to a lab was an inconvenience and relatively expensive. Monthly testing was used because it reduced the cost for testing (by limiting it to monthly, instead of weekly), and reduced the inconvenience to the patient. (And, as noted above, non-compliant patients dropped out of the program).

Some people are simply unable or unwilling to do self-testing. Not all doctor's offices are equipped to do in-office self-testing.

Perhaps the prevailing wisdom will come around to the importance of weekly testing -- and for those who CAN self-test, this SHOULD be done, with meters and consumables readily available.

---

After a while, you can sort of get used to lancing a finger for a weekly test. It's easy to avoid, but it's important.

---

It looks like I'll have to do some bridging in a month or two -- after 66 years, I think that I'll finally get a colonoscopy. I'll have to bridge for that. Because I've got my own meter, I'll be able to determine when my INR gets back into range, and may end up not bridging for as long as I would without a meter to confirm that my INR is back in range.

 

[rnff2]

I agree with you about weekly self-testing. I've been evangelizing about it for years.

There are a few reasons why weekly self-testing isn't more widely accepted:

The clinics that use protocols calling for monthly or even bi-monthly testing have a great success record. For patients who die or become incapacitated between tests, these patients simply 'drop out' of the program. I doubt that many anticoagulation clinics (or even research organizations who watch this stuff) ever question WHY people drop out of the program.

There was a time not too long ago when there were no readily available meters for self testing. Going to a lab was an inconvenience and relatively expensive. Monthly testing was used because it reduced the cost for testing (by limiting it to monthly, instead of weekly), and reduced the inconvenience to the patient. (And, as noted above, non-compliant patients dropped out of the program).

Some people are simply unable or unwilling to do self-testing. Not all doctor's offices are equipped to do in-office self-testing.

Perhaps the prevailing wisdom will come around to the importance of weekly testing -- and for those who CAN self-test, this SHOULD be done, with meters and consumables readily available.

---

After a while, you can sort of get used to lancing a finger for a weekly test. It's easy to avoid, but it's important.

---

It looks like I'll have to do some bridging in a month or two -- after 66 years, I think that I'll finally get a colonoscopy. I'll have to bridge for that. Because I've got my own meter, I'll be able to determine when my INR gets back into range, and may end up not bridging for as long as I would without a meter to confirm that my INR is back in range.

I completely agree with everything you said.

Just look at the diabetic population. If it weren't for home glucose monitoring where would these people be. Granted INR monitoring is less frequent than glucose monitoring but important in its own right. Pricking your finger at some point becomes necessary and not an option as in the case of diabetics and it's really no different than INR testing. You have to do what you have to do.

You can't make people be compliant but when things are made easier for the patient the compliance increases.

I also think the overall cost needs to come down for this to become more readily available in addition to MD's trusting the results.

As I started my valve replacement and coumadin journey I asked up front for home monitoring and it probably would have made a difference in my valve choice if home monitoring wasn't going to be available to me.

Good luck with your colonoscopy. Bridging isn't too bad, aside from the lovonox burning at the injection site for about 20 minutes after the injection...ouch.

 

[Protimenow]

I've bridged before. The burning isn't always too bad. I don't know when this procedure will happen - my doctor wants approval from my cardiologist, and the gastroenterologist seems to be booking these things about a month out.

Regarding cost of the INR testing:

It would be great if the costs continue to drop. For now, discounting the cost of the meter, as you know, test strips are around $5 or so U.S. With enough experience, there aren't too many strips wasted.

As far as Glucose testing is concerned, I realize that individual tests don't cost too much -- but I've heard of some diabetics who may test three or more times daily. The cost, over a week, may approach that of the INR test strips. (I don't know - I'm fortunately not a diabetic, so I'm not especially familiar with the cost of the strips or the testing frequency). I DO know that the meters have become nearly giveaway items - kind of like the razors and blades analogy.

There's no conceivable way that the number of INR meters and strips will ever approach the sales volume of glucose testing (unless some easy method is developed for an artificial pancreas, or something, that reduces the need for regular blood glucose monitoring), so the cost of meters and strips may remain high. OTOH - if EVERYONE who is taking warfarin is allowed and encouraged to get a meter and self-test, the numbers can rise significantly - perhaps significantly enough to bring costs of both down. The increase in the percentage of warfarin users whose INRs are always in range - and who can demonstrate that their INRs ARE in range - can point to reduced overall costs of care - and may even spur government subsidies for INR self-testing.

One can only hope.

 

[rnff2]

I tried to post a couple times after surgery last week but the forum was down...sorry for the late update.

I'm 9 days post op gallbladder surgery and doing great. Bridging was easier than I expected, even with little support from my cardiologist's nurse (long story). I have a rainbow of bruises on my belly right now from the coumadin and the surgery, I'm very colorful. Lol.

I will say that laproscopic gallbladder surgery was way easier than open heart surgery. I was taken into OR at 1250pm and was home by 6pm (I don't remember what time we actually left the hospital) and that was after stopping to drop off a prescription and pick up dinner, and did I mention we stopped at my son's soccer practice too, yep, way easier than OHS.

Thanks again everyone.

 

[Protimenow]

I'm glad that it went so well. Some of that abdominal bruising is probably related to those Lovenox injections you had to give yourself for the day or two (or three) pre-op and post-op.

 

[rnff2]

I'm glad that it went so well. Some of that abdominal bruising is probably related to those Lovenox injections you had to give yourself for the day or two (or three) pre-op and post-op.

Thanks, it went so well I'm going back to work tomorrow.

Yes, the lovonox made for some colorful bruises.

 

[pellicle]

.., the lovonox made for some colorful bruises.

every time I read that word I read "Love 'n Ox" ... my father used to swear by saying "Love a Duck!" ... so naturally I found this product amusing:

so perhaps they could leaverage a free advertising slogan from me?

 

[Protimenow]

Not that this has any relevance to the thread, but I just learned that 'Ox' and 'Oxen(plural of Ox) were JOB DESCRIPTIONS. If they weren't doing that kind of work, they'd just be cattle.
It kind of makes me wonder what MY title should be...