Coumadin Vs Warfarin

[BECKY]

I haven't been on line for Soo long. Coming on and seeing what is going on I realize I've missed it. My job has changed and I just don't have the time anymore. I am on for some special questions. My father-in-law is 82 years old and recently hospitalized for internal bleeding. He had heart surgery 10 years ago...by pass and Aortic Vavle replacement. (artificial) He was on coumadin and at some point he was changed to warfarin. He has had 4 bleeds in the last 5 years. This last one he needed 9 units of blood. He had the blood collect in the cavity around his organs and coagulate putting pressure on his nerves and making him loose use of his one leg. That is what ended up sending him to the Dr...thus the hospital. That was 5 weeks ago. This Sunday they are sending him home...they say. What they have suggested is that he can't tolerate any anticoagulant and they are suggesting they replace his artificial valve with a pig valve so he won't need the drugs.

I think this is a very risky option for a man who seems frail to begin with. This had been their goal...to get him strong enough to have the surgey. He has been having physical therapy in the hospital the last two weeks. He was too weak to do anything prior to that he couldn't even get out of bed. My husband and I are very skeptical about this surgery. I think they should monitor him more closely. Reading about the problems that are possible with 1. Warfarin or 2. switching from one to the other I wonder if this could be his problem. I wonder why the Dr. he has wouldn't be aware of potential problems especially with the history he has had in the last 5 years. Could he possibly be okay if they went back to the coumadin instead of warfarin. I know cost is always an issue.

My father in law lives right outside of Williamsport and we live outside Phila. We haven't had contact with the Dr. My husbands sister is doing all the contact. The first time we heard about this surgery, which would be done at Geisinger Medical Center. When his sister talked to a surgeon there...the first surgeon said he wouldn't touch it with a ten foot pole. Other surgeons, we were told, couldn't agree with what to do. He is presently in Lewisburg Hospital.

I hope the good Dr. has an asnswer. Are there people that are intolerant to anticoagulants? Even after they have been on them for 10 years. Is this the only option? My husbands family thinks either he has this surgery or he will bleed to death.

I have been on coumadin for almost 19 years. I have three artifical vavles and they keep me on the thin side. I am not steady. My INR's are up and down all the time and I get check usually every two weeks. Rarely three weeks but I am very inconsistant. I am tired of all the blood work but I know this is my life. I wish I could be stable and only have to go once a month but I'm not. Does age have anything to do with it? Will I end up like him?

BECKY

 

[ALCapshaw2]

I didn't see any mention of his INR level.
Is he being monitored properly and regularly?

Is he taking his warfarin on schedule
(and NOT overdosing)?

IF all of the above is OK, and replacement is recommended (by more than one doc), I would look at the Carpentier-Edwards Bovine Pericardial Valve instead of Pig Valves. The pericardial Cow Valves last 50 to 100% longer than Pig Valves.

The Cleveland Clinic is a strong advocate of the Bovine Pericardial Valves and should have LOTS of experience with them. It might be worthwhile having him evaluated at the Cleveland Clinic since it is the #1 rated Heart Hospital and not too far from PA.

'AL'

 

[BECKY]

Al,

When we ask my husbands sister what his INR had been before he went in the hospital all we are told is it was fine. I dont' think she knew a number then. The last we heard is they want to keep him between 1.7 and 2.0.

 

[Nancy]

Hi Becky-

I'm so sorry for this poor man. He's been through a lot. Something doesn't sound right with his condition. I'm sure right now, because of the bleeding, they want to keep him low for a little while, but he has a mechanical valve and he should be up higher.

Does he live alone? Does someone keep an eye on what he's taking as far as his dosage? It's so easy to get confused, especially if you aren't feeling well to begin with. How often is his INR checked? Maybe you should give his doctor a call and find out what his INRs have been running, since you are very familiar with how it is dosed and what the target INR is.

My husband has been on Coumadin for 25 years, and has never had a bleeding incident related to Coumadin. He's 71 years old. But it takes vigilance with monitoring and dosage, as you know from your own experiences.

If he could avoid heart surgery at this time in his life, that would be a good thing.

I think you need to delve into this deeper to get the answers that you need. It's sounds as if you are the family Coumadin expert.

I know that Al Lodwick will see this soon and give you his feelings on warfarin vs. Coumadin.

Best wishes to you and to your father-in-law.

 

[Guest]

I am dealing with two people in a similar situation right now. Both men ages 65 and 76. Both have valves. The 65 year-old is in reasonable health except for bleeding. The 76 yo is frail. My usual philosophy is to keep the INRs to the high side - easier to deal with a bleed than a clot, but these guys have serious bleeds.

I would probably handle your F-I-L with the INR of 1.7 to 2.0 like is being done. (Except that it is almost impossible to keep it in that narrow range.) I would guess that at his age and debilitated state that he has little chance of making a full recovery after surgery. I would discuss all of this with him. If he has been living alone, I would assume that he can participate in decisions like this.

1. He isn't like to tolerate a surgery.
2. The BEST INR is 2.5 to 3.5 but this caused him to use 9 units of blood.
3. Therefore, the next best thing is to lower the INR goal.
4. This will offer a little less protection from a clot. (How much less is unknown.)
5. It is probably the most reasonable compromise.

If he is still in the hospital, it is easy to find what his INR was on admission. It is still in his chart and the computer.

Find out what it was and what caused it to be there. Did he get confused and take the wrong medication? He may need someone to set up his meds and take them out of the house so he cannot get to them if this was the case.

Did he stop eating? Not uncommon at his age and makes the INR go up.

Was he taking antibiotics? That could make the INR go up.

Getting the most accurate answer you can will help decide what to do.

Will it happen to you. Probably not. There will be a replacement for warfarin before you get to be his age.

 

[BECKY]

Al,

Thanks so much for the advice. My Father in law is already convinced that he has to have this surgery or he will bleed to death.

We don't know if he may have been confused and overdosed. He does have a big pill container with daily compartments and time of day for one a day or two a day etc. I don't know how he keeps it all straight but he is on alot of medication.

He does also go with out eating so he seems to be always a constant diaster waiting to happen. He is married and she is younger and sharp but I don't think she does anything with medication at all I think he is in control of that.

I am just beside my self with concern because I know how difficult the second surgery was for me as far as recovery. I can't imagine him being able to do it.

It sounds like he will come home Sunday and go to Geisinger for testing and possible surgery next Wednesday. They want to operate before he has another set back.

Thanks for your advice again I really appreciate it.

BECKY

 

[Weezie]

Weezie

Weezie

Becky, what is the status of his liver function tests? What about alcohol use at home? Does he have any aneurysms (surely these would have shown up in imaging) and could he have a leak there (any dissecting aneurysm mentioned)?

Allodwick - you there on this string? Correct me if wrong, but just as in any medication, there could be an allergy reaction, right? I'm certainly not a pharmacist, but in my advanced pharmacology course I had to take for NP cert, Coumadin/warfarin was said to be one of those meds that should be "stuck with" whichever one was the initial Rx, as I recall. I.E., if started on Coumadin name brand, should not switch to generic because may have to start over w/ the stabilization process; reverse also maybe true. I think one would have to be concerned with dose compliance and med interactions - I know I have to set my alarms every day to remember to take my meds when I get really busy! And if I didn't have my AM/PM med box, I would sometimes probably scratch my head and say "Did I take that or not?"

Hard to decide on surgery risk vs. quality of life - have you discussed it in a very straightforward manner with him, and does he have a Living Will? I quite well remember 20 years ago, when I was a cardiac specialty nurse, bypass surgery was being considered for a patient in her 97th year and one doc said "Who wants to be 98 anyway?" to which another replied "Anyone who is 97." I firmly believe that the choice is his if he has the mental capacity to make an informed choice and has not been declared incompetent.

 

[Guest]

This thread's last entry was 3 years ago.

 

[Weezie]

Weezie

Weezie

Thanks, Al - obviously not accustomed to the sity yet. I will look more carefully for dates. Again, thanks for "heads up".