Colonoscopy

[Juli]

Thank you all - that is very helpful information.

I got some extra test strips and will also record daily measurements and dosage. I am at 10 mg (4x/week) and 9 mg (3x/week) - so will follow the idea to "kick start" the dosage the first 2 days or so. Looking at the graphs it clearly shows that the 10% change (1 mg) is too low and only good for a steady state condition - not so much for the start up.

Pellice - I assume reading the graph that after the colonoscopy you got back to the same dosage as before. Did you take Heparin injections during the period when your INR was below target or just wait it out? I was instructed to take Heparin injections - except for 24h before the colonoscopy - and then to continue on Heparin until my INR is back in range - of course would like to keep the time post colonoscopy short.

 

[Mister_James]

The only thing to be aware of is that if they do remove polyps. They have clips to seal the snips and they do reduce bleeding but bridging takes care of your coagulation so you will experience some bleeding.
I had my procedure at 1.7 INR and I started back warfarin and bridging the evening after the procedure and I had significant bleeding for 3 days so I stopped Lovenox after 2 shots and let warfarin slowly do it thing.
Clots take time to build up and you have no stores of vitamin K during the time of the procedure because you will not be eating greens or fiber rich foods.

 

[Mister_James]

The procedure is usually to start bridging under 2.0 and skip a dose before the procedure that would give you about 16 hours period before the procedure, some healing time and restart the same time you had your last dose that's 24hrs without bridging and you also restart Warfarin.
Most colonoscopies are in the morning and you can adjust your bridging to give you as much leeway as you need.

 

[Chuck C]

Not nearly enough. Check my graph (from the blog post) again carefully. Remember graphs are not just pictures they are the numbers ... (sorry if you were already thinking that way, but many seem to forget it after primary school)

View attachment 887851
So, my graph is a little complex, as you can see it has two Y-axes (one for INR, the other for dose in mg because its presenting two entirely different things together in a relationship). I explain that in the post. Quoting from that blog post:

My process was this:

• measure INR daily (in the AM, usually about 8am)
• my usual dose time is 7pm
• I charted INR and dose
• the graph below has INR on the LHS Y axis and dose in mg on the right axis
• the bars represent actual data and the lines part of my model
• my colonoscopy was Wednesday

So reading across (left to right) you can see that I had my last dose on Saturday (don't ask me why I did the half dose rather than just go off.

As I expected (from recording previous situations) it took until Wednesday (the exact day of the colonoscopy) to reach the agreed INR.

I then took 9mg (which7mg +30% extra) and observed that it was not coming up at a good rate (not unexpected, but one has to do the experiment right?) and so on Friday I took 12mg (or nearly 80% more). I then took 8mg until the following Wed when (being concerned about a possible overshoot {see the magenta ellipse}) I reduced back to my normal dose and then managed "normally".

So, as @Keithl has suggested double doses in the first two or maybe 3 days would get you there faster. Plinking around with an increase of 10% is like putting a cup of water into the bath to raise the level.

This graph shows an estimation of the "load" of warfarin that accumulates in your body as a result of resuming taking dose of 5mg

View attachment 887852
it takes about 6 days to get to steady state (its theory right, practice will be slightly different), and so the INR will lag behind that by one or two days.

Now if you take double the dose in the first two days you will see this

View attachment 887853

where the accumulation load will get there faster and then roll off to the "steady state (follow along the blue line for dose right .

To me its uncertain what sort of INR effect this will have, so myself I'd be inclined to do with a staged double, then decreasing

View attachment 887854

anyone have any thoughts on the above?

Great information! Thanks for taking the time to upload your own personal data! I will certainly refer back to this post when it comes time for my colonoscopy, which may be relatively soon as I am past due.

 

[pellicle]

Hi

Pellice - I assume reading the graph that after the colonoscopy you got back to the same dosage as before.

yes, here is my 2017 data for INR and dose

Did you take Heparin injections during the period when your INR was below target or just wait it out?

I did, from my blog post (I'll underline it here):

Summary position

• With good data you can manage your INR down to a suitable level for a small procedure probably without need for heparin (but be prepared for needing it)
• I have again verified my model in an actual experiment but with better data gathering than before
• I was perhaps too conservative in my management strategy (but who knows)
• the outcomes were all good
• I took a Heparin shot in the middle of the 'recovery of INR' phase (for "just in case"), pehaps it was too conservative but what the hell ...

 

[Keithl]

Not nearly enough. Check my graph (from the blog post) again carefully. Remember graphs are not just pictures they are the numbers ... (sorry if you were already thinking that way, but many seem to forget it after primary school)

View attachment 887851
So, my graph is a little complex, as you can see it has two Y-axes (one for INR, the other for dose in mg because its presenting two entirely different things together in a relationship). I explain that in the post. Quoting from that blog post:

My process was this:

• measure INR daily (in the AM, usually about 8am)
• my usual dose time is 7pm
• I charted INR and dose
• the graph below has INR on the LHS Y axis and dose in mg on the right axis
• the bars represent actual data and the lines part of my model
• my colonoscopy was Wednesday

So reading across (left to right) you can see that I had my last dose on Saturday (don't ask me why I did the half dose rather than just go off.

As I expected (from recording previous situations) it took until Wednesday (the exact day of the colonoscopy) to reach the agreed INR.

I then took 9mg (which7mg +30% extra) and observed that it was not coming up at a good rate (not unexpected, but one has to do the experiment right?) and so on Friday I took 12mg (or nearly 80% more). I then took 8mg until the following Wed when (being concerned about a possible overshoot {see the magenta ellipse}) I reduced back to my normal dose and then managed "normally".

So, as @Keithl has suggested double doses in the first two or maybe 3 days would get you there faster. Plinking around with an increase of 10% is like putting a cup of water into the bath to raise the level.

This graph shows an estimation of the "load" of warfarin that accumulates in your body as a result of resuming taking dose of 5mg

View attachment 887852
it takes about 6 days to get to steady state (its theory right, practice will be slightly different), and so the INR will lag behind that by one or two days.

Now if you take double the dose in the first two days you will see this

View attachment 887853

where the accumulation load will get there faster and then roll off to the "steady state (follow along the blue line for dose right .

To me its uncertain what sort of INR effect this will have, so myself I'd be inclined to do with a staged double, then decreasing

View attachment 887854

anyone have any thoughts on the above?

So I had my Colonoscopy Wednesday and GI said resume meds. I was bridging with Lovenox so that night I took 5mg (normal dose is 7.5) then following AM went to my normal 7.5. Last time it took 6 days to get to 1.7 which in theory is OK for my On-X and 10 days to get over 2.0. This time I am going to spike my does 3mg 2 more nights (I take normally in AM) for a few days and see if I can get closer to 2 faster. My PCP mentioned that years ago they would double your dose for 2 day to get you ramped up before all the bridging. Lovenox is annoying me this time as it is bruising me, which I don't recall last year.

I see On-X is doing Eliquis trials at minimum maybe they will approve Eliquis as a bridging option vs. the Lovenox injections.

 

[pellicle]

Hi

So I had my Colonoscopy Wednesday and GI said resume meds. I was bridging with Lovenox so that night I took 5mg (normal dose is 7.5) then following AM went to my normal 7.5. Last time it took 6 days to get to 1.7 which in theory is OK for my On-X and 10 days to get over 2.0.

personally I'd like to get higher sooner than 6 days, but I guess its not really an issue.

Why did you start on 5 instead of like 10? I see you're intending to add about 50% on the subsequent doses.

This time I am going to spike my does 3mg 2 more nights (I take normally in AM) for a few days and see if I can get closer to 2 faster.

just be cautious of overshoot .... and discontinue the heparin as soon as in range because:

Lovenox is annoying me this time as it is bruising me, which I don't recall last year.

suggesting you may be slightly different this year

PS: I'll go out on a limb here and suggest that you'll be in range by 5 days based on your above mentioned regime

 

[Keithl]

Hi



personally I'd like to get higher sooner than 6 days, but I guess its not really an issue.

Why did you start on 5 instead of like 10? I see you're intending to add about 50% on the subsequent doses.



just be cautious of overshoot .... and discontinue the heparin as soon as in range because:


suggesting you may be slightly different this year

PS: I'll go out on a limb here and suggest that you'll be in range by 5 days based on your above mentioned regime

After my bleed last time I was scared to start day of, he said OK, but he did remove 5 polyps. So I took 5mg that night then my regular 7.5 next morning and 7.5 today. I tested this evening and saw 1.3 and sai let's spike the dose with a kicker (3mg) each night for another night or 2 and I will re-test Sunday (Friday today).

 

[pellicle]

After my bleed last time I was scared to start day of, he said OK, but he did remove 5 polyps.

I understand that ... I was quite concerned in my last colonoscopy too because (as mentioned in my blog) a friend bled very seriously after his. Its not of any consequence, I was just interested is all.

However the influence of warfarin is not as fast as heparin and has to build up to a level before its effective)

Best Wishes

 

[coffeelover]

Really Good information shared with this thread! ...I'm needing to schedule a Colonoscopy, but I am nervous about colonoscopy due to anticoagulation meds for Mechanical Aortic valve..( warfarin and aspirin on board). Due to no family history and "clean" colonoscopy 10 years ago, my Cardiologist shared I could consider doing a Colongard test. Does anyone know if Insurance covers this test? Also, does anyone know if having other cancers in your family history ( like Liver, pancreatic) Increases risk of Colon cancer? Thanks for your help!

 

[Keithl]

Actually it is rather a non-even unless they remove big polyps, they they should cauterize them or be sure they have fully sealed them. They took a 10mm and 15mm flat polyps (would have definitely become cancerous) that were difficult to remove and they clipped it. Well 2 days later as I went back to warfarin and bridging (morning after) I was bleeding and was in hospital for 2.5 days as they prepared me for yet another colonoscopy to go in and close them off well. This time while they took a bunch of polyps they were evidently not bleeders to now 4 days later I am fine. This time the Lovenox shot are bruising me more, not sure why. Since I have an On-X and take baby aspirin my INR is back to 1.7 today and will stop the bridging after tonight's shot. I did spike myself with extras doses of warfarin (as mentioned before) to get INR up quicker. I normally take 7.5mg, but added 3mg for 3 days to get this up as last time it took 9 days to get me above 2.0.

I have family history so Colongard is a no go for me. And honestly it's success is not as good as the tired and tur colonoscopy. I will deal with the prep every 2 years now for the safety of knowing they see everything witht he scope.

 

[Keithl]

Wooho, 5 days to INR of 2.2. This is about half the time as last time. I took my normal 7.5mg each morning and then added 3mg each evening for 3 nights. Now back to just my normal dose. Far better than the 9 days to 2.0 last time.

 

[slipkid]

...... Lovenox is annoying me this time as it is bruising me, which I don't recall last year.

The only time I've had to bridge with it (for a cardiac cath/stent) my entire abdomen/etc was one huge black, blue, and blood-red mess. The Dr and his staffdoing the procedure even commented on how bad it was.

I see On-X is doing Eliquis trials at minimum maybe they will approve Eliquis as a bridging option vs. the Lovenox injections.

That would be great if ever approved for bridging. Until then I am avoiding any procedures that require bridging with lovenox unless no other choice etc.

 

[Juli]

I wanted to report back to the forum how my bridging for the Colonoscopy worked out. After doing a lot of reading I came across the following study ("Loading dose vs. maintenance dose...") that did make a lot of sense to me:

https://pubmed.ncbi.nlm.nih.gov/24837794/
So I did follow the doctor's protocol to stop taking Warfarin 5 days before the colonoscopy, start Enoxaparin 3 days (2 injections/day) with last injection 24h prior to colonoscopy. Upon return from the procedure and for the next day I doubled my daily Warfarin dose and only had to take one day 2x Enoxaparin shots. As you can see in the table the INR (which I measured daily during this time) recovered quickly and reached target on day 5 post colonoscopy. My target range is 2.5-3 INR and going into the procedure I was a little bit higher than normal - no idea why.

Based on my experience and also on the study this appears to be a viable approach - unfortunately I have to do this again at the end of September for a repeat Colonoscopy. They took a biopsy and I had no bleeding complications.

I hope this might help others.

 

[Keithl]

You are lucky to get your INR back that fast. I did not double this time, but added 3mg to my 7.5 and within 5-6 days was back within range compared to 9 if if just took my regular dose. Next time I may add 5mg for a few days as I don’t want to overshoot.

 

[Beach77]

So I did follow the doctor's protocol to stop taking Warfarin 5 days before the colonoscopy, start Enoxaparin 3 days (2 injections/day) with last injection 24h prior to colonoscopy. Upon return from the procedure and for the next day I doubled my daily Warfarin dose and only had to take one day 2x Enoxaparin shots.

Thank you for this Juli! My doctor gave me the same protocol for my colonoscopy in a couple of weeks. This has eased some of my concern about skipping a couple of doses before the injections. Interesting about starting your doses up again! I've read a few other postings about this too. Thank you for sharing!!!