Dosing for tooth removal

[Old clicker]

Hi Everyone. I haven't been around here for a long time. I had my aortic valve replaced in 2004 with a mechanical valve. But enough about me. In November 2018 my wife had a heart attack, she had 3 bypasses, her mitral valve replaced with a mechanical valve, and a band put on her tricuspid valve. She is on warfarin and they want her to be between 2.5 to 3.5. It takes between 40 to 45 mg per week to stay in range.
She has to have a tooth extracted, and they want her to be 2.0 or lower for the procedure. I think maybe we have to withhold for 2 days, and go back on the regular dose on the procedure.
What would anyone here recommend, or am I close?

 

[Protimenow]

In my experience, it takes about two days to get the INR low enough -- if it's too high, it can take a LONG time for the open gum to clot. You may even want INR lower than 2. Talk to your dentist about this.

What's also important - maybe MORE important is taking antibiotic before (and maybe after) the procedure. I've taken Amoxicillin, and I'm pretty sure that this may be what you're given.

As far as INR, she can start taking her usual dose right away -- within three days, the INR should be back where it should be (at least, this has been my experience). (The antibiotic MIGHT interfere with the INR, but after three days of normal warfarin dosing, the effects of the antibiotic should be gone, and the INR will probably be back where you want it). If you have an INR tester, test after three days, if you can, and maybe after a week, just to confirm that the INR is where it should be.

There should be low or minimal risk of any negative consequences if the INR is below 2 for a week or so. You should consider testing before the procedure, just to be sure that it's low enough to keep the dentist comfortable. I don't know that two days without warfarin is a hard and fast rule for dropping below 2, but it's worked for me.

 

[Old clicker]

In my experience, it takes about two days to get the INR low enough -- if it's too high, it can take a LONG time for the open gum to clot. You may even want INR lower than 2. Talk to your dentist about this.

What's also important - maybe MORE important is taking antibiotic before (and maybe after) the procedure. I've taken Amoxicillin, and I'm pretty sure that this may be what you're given.

As far as INR, she can start taking her usual dose right away -- within three days, the INR should be back where it should be (at least, this has been my experience). (The antibiotic MIGHT interfere with the INR, but after three days of normal warfarin dosing, the effects of the antibiotic should be gone, and the INR will probably be back where you want it). If you have an INR tester, test after three days, if you can, and maybe after a week, just to confirm that the INR is where it should be.

There should be low or minimal risk of any negative consequences if the INR is below 2 for a week or so. You should consider testing before the procedure, just to be sure that it's low enough to keep the dentist comfortable. I don't know that two days without warfarin is a hard and fast rule for dropping below 2, but it's worked for me.

 

[Old clicker]

In my experience, it takes about two days to get the INR low enough -- if it's too high, it can take a LONG time for the open gum to clot. You may even want INR lower than 2. Talk to your dentist about this.

What's also important - maybe MORE important is taking antibiotic before (and maybe after) the procedure. I've taken Amoxicillin, and I'm pretty sure that this may be what you're given.

As far as INR, she can start taking her usual dose right away -- within three days, the INR should be back where it should be (at least, this has been my experience). (The antibiotic MIGHT interfere with the INR, but after three days of normal warfarin dosing, the effects of the antibiotic should be gone, and the INR will probably be back where you want it). If you have an INR tester, test after three days, if you can, and maybe after a week, just to confirm that the INR is where it should be.

There should be low or minimal risk of any negative consequences if the INR is below 2 for a week or so. You should consider testing before the procedure, just to be sure that it's low enough to keep the dentist comfortable. I don't know that two days without warfarin is a hard and fast rule for dropping below 2, but it's worked for me.

I also thought below 2 would be better, but the Dentist said 2. We take Amoxicillin even before cleaning, and will for the extraction. He wants to test within 24 hours before the procedure just to make sure it's low enough. Perhaps we should stop 3 days before the procedure. She had a colonoscopy a couple months ago, and we had to stop a week before, back on the regular dose the day of. She was on fragmin for about a week until it came back into range.

 

[pellicle]

Hi

You need to be a self tester to he sure of this (to be able to get data, so you aren't flying blind).

think maybe we have to withhold for 2 days, and go back on the regular dose on the procedure.

Plan to have INR at 2 it perhaps 1.5 for the surgery. I'm sure you can do this by dropping your dose to about half (perhaps less) for maybe 3 days (it depends).

After surgery resume your regular dose (or perhaps take a double dose first then resume on regular dose). It's not critical, as the body heals quickly for knocked out teeth.

Carefully read this and the linked articles and hit me up with specific questions

http://cjeastwd.blogspot.com/2022/05/rapid-dust-off-inr-management.html
Best wishes

 

[tom in MO]

Don't bet your wife's life on advice from the internet. She should talk to the person prescribing her warfarin. In my case, it's the cardiologist.

On 3 occasions I've had to drop my INR for a procedure. The doctor's performing the procedure wouldn't do it until I consulted with my cardiologist for how to bring my INR down and then back up. My cardiologist does not charge for this service. Two of the procedures the surgeon's nurse tested my INR to make sure it was low enough before the work commenced. My cardio doesn't have me slowly go off or back on warfarin. It's cold turkey for a few days before (depending on how high my INR is) and then full dose either after surgery or the next day.

A family member had to go off warfarin for surgery to replace her valve and she did have a stroke. However her stroke was mild and she recovered. The risk is real.

 

[Old clicker]

Don't bet your wife's life on advice from the internet. She should talk to the person prescribing her warfarin. In my case, it's the cardiologist.

On 3 occasions I've had to drop my INR for a procedure. The doctor's performing the procedure wouldn't do it until I consulted with my cardiologist for how to bring my INR down and then back up. My cardiologist does not charge for this service. Two of the procedures the surgeon's nurse tested my INR to make sure it was low enough before the work commenced. My cardio doesn't have me slowly go off or back on warfarin. It's cold turkey for a few days before (depending on how high my INR is) and then full dose either after surgery or the next day.

A family member had to go off warfarin for surgery to replace her valve and she did have a stroke. However her stroke was mild and she recovered. The risk is real.

We have a Dr appointment coming up to decide what we need to do. I am just checking out other peoples opinions before our appointment.

 

[pellicle]

family member had to go off warfarin for surgery to replace her valve and she did have a stroke. However her stroke was mild and she recovered. The risk is real.

Sorry to hear about your family member. Yes the risk is real, but it's not equal for everyone.

Further as I assume you are familiar with peer reviewed journals and their purpose to inform medical specialists you should stop with the oblique ad hominem attacks and try to educate yourself.

Best Wishes

 

[RainnPomela]

First off, sending positive vibes to your wife for a smooth procedure. Regarding the warfarin adjustment, I totally get your concern. When my dad had a similar situation, his doctor advised a brief pause in his medication before dental work

 

[Buck83]

I am having an endoscopy next week and my cardiologist has me stopping my warfarin 2 days prior and not starting back until 2 days after. He also has me bridging with lovenox while I’m off the warfarin. I have a history of clots and had a mild stroke last year so I will bridge with lovenox anytime I have a procedure. Might be worth discussing with her cardiologist.

 

[MdaPA]

I am having an endoscopy next week and my cardiologist has me stopping my warfarin 2 days prior and not starting back until 2 days after.

Do you know why your Cardo said not to start back warfarin until 2 days after?

 

[Buck83]

Do you know why your Cardo said not to start back warfarin until 2 days after?

I assume to let whatever possible damage that may be done heal? But I didn’t ask. I’ll just give myself the shots in the belly for 5 days and then start back.

 

[MdaPA]

I assume to let whatever possible damage that may be done heal?

But you are going to take Lovenox shots 12-24 hours post-procedure/surgery, especially given your history of clots, right?

 

[Buck83]

But you are going to take Lovenox shots 12-24 hours post-procedure/surgery, especially given your history of clots, right?

Yes. Will be giving myself lovenox shots for 48 hours post procedure then back on the warfarin!

 

[pellicle]

But I didn’t ask. I’ll just give myself the shots in the belly for 5 days and then start back.

I'm a bit lost ... so to be clear you're intending to

1. stop warfarin
2. commence heparin (I'll guess that you're using the brand of Lovenox)
3. cease warfarin 12 hours before you go to dentist
4. give the wound some time to heal (say, 12 hours)
5. commence warfarin and continue lovenox
6. measure INR daily until INR is in range
7. cease heparin

Because that is the standard method of "bridging" (per figure below)

As I understand it, bridging was devised in the dark ages before people understood that you can simply measure INR as often as you want using a Point of Care machine (such as a coaguchek) without vein draws. Bridging is used because people can't plan (because they can't be bothered) what they do or take notes.

What you described seems rather more risky because you were talking about "I’ll just give myself the shots in the belly for 5 days and then start back." Suggesting you won't recommence your usual prior dose for 5 days.

Am I understanding this?

 

[Buck83]

I'm a bit lost ... so to be clear you're intending to

1. stop warfarin
2. commence heparin (I'll guess that you're using the brand of Lovenox)
3. cease warfarin 12 hours before you go to dentist
4. give the wound some time to heal (say, 12 hours)
5. commence warfarin and continue lovenox
6. measure INR daily until INR is in range
7. cease heparin

Because that is the standard method of "bridging" (per figure below)
View attachment 890149
As I understand it, bridging was devised in the dark ages before people understood that you can simply measure INR as often as you want using a Point of Care machine (such as a coaguchek) without vein draws. Bridging is used because people can't plan (because they can't be bothered) what they do or take notes.

What you described seems rather more risky because you were talking about "I’ll just give myself the shots in the belly for 5 days and then start back." Suggesting you won't recommence your usual prior dose for 5 days.

Am I understanding this?

No. you aren’t understanding this. I’m not the original poster. I’m not having a dental procedure. I’m having an endoscopy. My cardiologist is taking me off warfarin 2 days prior and 2 days after. I will be on lovenox for 5 days and then back on warfarin

 

[pellicle]

well I didn't say "colonoscopy" but ...

My cardiologist is taking me off warfarin 2 days prior and 2 days after. I will be on lovenox for 5 days and then back on warfarin

I'm also referencing this:

So, you still need to follow the steps I mentioned above in that order including the testing because you'll be off warfarin for 5 days in total which may take longer than you think for your INR to return. This is why we measure.

Best Wishes

 

[MdaPA]

1. stop warfarin
2. commence heparin (I'll guess that you're using the brand of Lovenox)
3. cease warfarin 12 hours before you go to dentist
4. give the wound some time to heal (say, 12 hours)
5. commence warfarin and continue lovenox
6. measure INR daily until INR is in range
7. cease heparin

My question if bridging, regardless if having endoscopy or dental procedure, is shouldn't one commence with warfarin the same time as heparin/Lovenox post-surgery/procedure? i.e. why the need to delay warfarin restarting if I understand what Buck83 is saying as outlined below?

1. stop warfarin
2. commence heparin (using the brand of Lovenox)
3. cease warfarin 12 hours before procedure/surgery
4. give the wound some time to heal
5. commence Lovenox 12-24? hours after
6. commence warfarin 48? hours after and continue Lovenox
7. measure INR daily until INR is in range then cease Lovenox

 

[pellicle]

My question if bridging, regardless if having endoscopy or dental procedure, is shouldn't one commence with warfarin the same time as heparin/Lovenox post-surgery/procedure? i.e. why the need to delay warfarin restarting if I understand what Buck83 is saying as outlined below?

1. stop warfarin
2. commence heparin (using the brand of Lovenox)
3. cease warfarin 12 hours before procedure/surgery
4. give the wound some time to heal
5. commence Lovenox 12-24? hours after
6. commence warfarin 48? hours after and continue Lovenox
7. measure INR daily until INR is in range then cease Lovenox

I wasn't sure, which is why I asked.

Also I do not understand why step 6 is not in step 5

 

[Amy]

Boy I wish I had either a cardiologist or even a Coumadin clinic who I could trust with this kinda situation. Most of the ones I’ve met don’t have any idea at all. I hope yours do.

My initial thought reading this was ‘stop Warfarin completely for that many days?!’ (horrified gasp) but then... you say she’s on a 40-45 mg maintenance dose.... hmmmm.. I really don’t know.

The good news is, if you test enough this time (I mean with a point-of-care machine) both before and after the procedure, and keep track of the results, you’ll know for NEXT time; ) . Good luck.