Colonoscopy

[Mister_James]

I have the procedure scheduled in a week and I am talking to my cardiologist tomorrow. I have not seen in here a discussion of this procedure, whether to bridge or not given that there might be biopsy of polyps and what not.
My gastroenterologist left it to my Cardio to make the call and I got a preview of bridging therapy with Lovenox. I can't say I am looking forward to it.
Who has gone through this?
I have mechanical valve in mitral position with occasional atrial fibrillation.

 

[MdaPA]

I have not seen in here a discussion of this procedure, whether to bridge or not

I posted 2 links below that discuss this:

Yet Another Colonoscopy Question
Colonoscopy

FWIW, my wife who is on Coumadin for mechanical AV and MV's skipped the Colonoscopy and opted for the at-home Cologuard test.

 

[pellicle]

I have the procedure scheduled in a week and I am talking to my cardiologist tomorrow.

well then, perhaps print and take this along
http://cjeastwd.blogspot.com/2017/12/perioperative-management-of-inr.html

.. I have not seen in here a discussion of this procedure, whether to bridge or not given that there might be biopsy of polyps and what not.

I had some removed in that ...

My gastroenterologist left it to my Cardio to make the call and I got a preview of bridging therapy with Lovenox. I can't say I am looking forward to it.

to bridge or not to bridge is dependent on your clotting risk factors. I personally would not (with your mentioned history) be quick to resume Anti Coagulation Therapy (and that's what bridging is, replacing one ACT with another

Heparin is quick to act and quick to vanish, Warfarin is by nature more the furnace that needs to be stoked to keep ACT at the level needed; it gets cold more quickly than it reheats however.

Reach out if you wish to discuss more, but read that blog post (and linked journal article) carefully. By carefully I mean as if you were taking a test on this and don't want to fail.

Best Wishes

 

[Keithl]

I have the procedure scheduled in a week and I am talking to my cardiologist tomorrow. I have not seen in here a discussion of this procedure, whether to bridge or not given that there might be biopsy of polyps and what not.
My gastroenterologist left it to my Cardio to make the call and I got a preview of bridging therapy with Lovenox. I can't say I am looking forward to it.
Who has gone through this?
I have mechanical valve in mitral position with occasional atrial fibrillation.

I had a a colonoscopy 14 months ago. I bridged for 3-4 days before and started up next day on warfarin and bridged for over 5 days after before my INR got decent. Make sure your gastro knows you are a bleed risk. 2 days after I had a GI bleed that landed me in the hospital for 3 days and they had to go back in and reseal what they had removed. Not fun. There is a post from me on one of these threads. The Lovenox is a 2x a day shot, not bad. Check with your insurance as mine classified Lovenox as a specialty drug and it took longer for me to get it as I had to do it through one specific company to get it.

 

[Humboldtgrrl]

I posted 2 links below that discuss this:

Yet Another Colonoscopy Question
Colonoscopy

FWIW, my wife who is on Coumadin for mechanical AV and MV's skipped the Colonoscopy and opted for the at-home Cologuard test.

And after Cologuard results, re-evaluate whether a colonoscopy is justified or not.

 

[Keithl]

And after Cologuard results, re-evaluate whether a colonoscopy is justified or not.

If they remove polyps they will want you back for a real colonoscopy. I need to go back this year due to the size they found, I will always be on the real procedure plan.

 

[RAS]

I had a colonoscopy in early Feb. Per recommendation from my Cardio, bridged with Lovenox due to previous history of fibrin strands on my valve.

I stopped Warfarin 1/26 and was asked to start Lovenox when INR fell below 2.0. That occurred 1/29. Two shots per day 12 hours apart until the procedure on 2/1 (no shot that morning).

Resumed Warfarin 2/2. Plan was to continue Lovenox until INR reached 2.0. It was a steady, but slow upward trend and once it reached 1.6, I discussed with a cardio nurse the possibility of stopping shots at that point since INR was going in the right direction and I would have needed another Lovenox Rx to continue. She agreed.

Total of 15 shots. I know that sounds like a lot, but the shots weren't difficult or painful. They do leave noticeable bruising. As I temporary measure, I found it acceptable to reduce risk. Certainly would not want to go through that on a long term basis.

That's my experience. I can't make any recommendations on whether you should bridge or not. The decision depends on you and your Cardio's assessment of degree of risk in your situation and your own risk tolerance.

 

[Mister_James]

Thanks Pellicle and everyone.

My understanding from reading is that bleeding is the greater risk than thromboembolism.

My cardio wants daily INR to get us below 2.0 withold warfarin and bridge, resume warfarin a day after the procedure and continue till in therapeutic range.

For that, I have received 20 pre-filled syringes for 2x daily.

I love my greens and I eat a lot of fiber and both those are both forbidden this week. So it's not just a dosage adjustment, there is a dietary adjustment at the same time.

 

[pellicle]

Hi

I love my greens and I eat a lot of fiber and both those are both forbidden this week.

ahh ... well trust me, the "medication" they give you to "purge" you will do exactly that.

My proctologist (she hates it when I say that, so I don't say it in front of her anymore ;-) wanted me to have my INR down to only 1.4 for the surgery. I don't know how you are with numeracy but if you follow that time line and read my actions (as evidenced in the daily records of that graph) you can find that its preferable to re-start warfarin directly after the procedure (I delayed) and you may or may not hit yourself with the heparin needles if it hasn't gone back up to where you want after the third day.

The colon heals pretty fast, so I'd anticipate within 24 hours of the surgery you'll be fine (a friend of mine 2 weeks prior nearly died because of "a bleed" (he isn't on warfarin) due to "operator error" and "mis handling". He lost about 1L of blood out of his arse (perhaps more, and yes it was a bloody mess) at home on his bed. Nearly grounds for malpractice there.

Anyway, don't sweat the INR thing, drop it down, bring it back up ... please note how long that woman example in my blog post must have been failing in her "irregular" warfarin history ... probably years.

 

[tom in MO]

I was told by my colorectal surgeon that bridging was not needed for a colonoscopy. It's needed if they take samples or remove polyps. He said I had a choice, do it w/o bridging and risk having to repeat it if they need to take samples/remove polyps or bridge and it's one and done.

 

[RAS]

risk having to repeat it if they need to take samples/remove polyps

That's an interesting recommendation. Why would they not take the sample/polyp initially?
Bridging is before and after, but not day of the procedure. In other words the patient is not on any anti-coagulation med at that point. If Warfarin was held long enough in advance, then INR should also be back to normal.

In my case, I did not have any polyps, so don't know for sure what the resumption timing would be if something found, but I would assume delaying an extra day before resuming bridging/warfarin doses would be considered. I should have asked that question, but did not think of it.

 

[Mister_James]

I think there should be a sticky on procedures on warfarin and put all this wisdom in one place.

 

[pellicle]

I think there should be a sticky on procedures on warfarin and put all this wisdom in one place.

Since Ross departed us there has not been good maintenance of this site (and that's the kindest thing I can say).

However there are at least forums such as this forum
https://www.valvereplacement.org/forums/anti-coagulation.18/
and searching on topics brings it up.

A sticky which is out of date and people (bless them) often complain that a study written in 2010 is somehow out of date when it refers to fundamental and unchanged biochemistry.

 

[Rapidman]

If you are low risk with no significant family history consider cologuard.

 

[Mister_James]

Just to be clear cologuard is a polite screener that is not a standard. It is a decent screener. That said, a colonoscopy allows proper diagnosis and why have 2 a screener and polyp biopsy later?

I was 3.1 on Friday, withheld warfarin and I am 2.7 today. I expect to be around 2.0 on Sunday and about 1.5 on Monday...Probably the decay is exponential and it will drop even faster but I should be close to normal on Tuesday for my procedure. Studying Pellicle chart for my certification program.

Interesting study linked:
Bridging Study

"Blood samples were drawn an average of 14 hours after the last dose of enoxaparin was given and surgery was performed an average of 97 minutes after blood samples were drawn. At least some anticoagulant activity was found in the blood of 99% of the patients. Of these patients, 68% had enough residual enoxaparin effect to be considered fully anticoagulated and 16% had even higher levels."

 

[Rapidman]

Cologuard is now a standard for low risk patients without a significant family history

 

[pellicle]

I was 3.1 on Friday, withheld warfarin and I am 2.7 today. I expect to be around 2.0 on Sunday and about 1.5 on Monday

as reported on my blog I had this:

so it'll be interesting to see your rate of drop.

BTW next time I didn't bother so much.

Best Wishes with the "purge"

 

[Mister_James]

Withheld Warfarin on Friday with 3.1 INR
Saturday evening I was at 2.7 INR
I wish I could say I am a brave soul but I couldn't sleep Saturday night and I tested again Sunday morning and I was at 2.4 INR (6 am) so probably 2.1 this evening and on track to be under 1.5 by Monday and for my procedure on Tuesday morning.

Having a mechanical mitral valve (St Jude) and AFib. I intend to bridge later today and not have to worry myself sick all night.
The only plan I am making now is maximising the time between my last Lovenox shot and the procedure. 4 - 6pm on Monday evening for a 10am procedure.

 

[pellicle]

Having a mechanical mitral valve (St Jude) and AFib. I intend to bridge later today

Prudent

 

[tom in MO]

That's an interesting recommendation. Why would they not take the sample/polyp initially?...

Bridging is only needed if they take remove tissue (e.g. polyps, samples, etc.). Most colonoscopies do not include those activities. So you can have a colonoscopy on warfarin. If they find things they want to sample or things they want to surgically remove, you'll need a second colonoscopy w/o warfarin. So you bet right, one and done, no risk of stroke from being off warfarin. If you bet wrong, two colonoscopies within a couple of weeks. The second one being off warfarin.