Five days off Coumadin for Cortizone shot

[TomS]

My back doc wants to take me off of Coumadin for five days for a corizone shot due to a pretty bad back problem. He's checking with my cardiologist who is very conservative, but I wanted to get some Forum advice in the meantime. I have an Atrial Valve Replacement, St. Jude mechanical, and AAA fix. Anyone had a similar experience or thoughts?
Thanks,
Tom

 

[dick0236]

I would not go off Coumadin/warfarin for 5 days. In my opinion, the risk of stroke is too great. Your cardio and "back" doctor need to closely coordinate this situation.

 

[njean]

My back doc wants to take me off of Coumadin for five days for a corizone shot due to a pretty bad back problem. He's checking with my cardiologist who is very conservative, but I wanted to get some Forum advice in the meantime. I have an Atrial Valve Replacement, St. Jude mechanical, and AAA fix. Anyone had a similar experience or thoughts?
Thanks,
Tom

OMG! My answer is NO to being off coumadin for 5 days! That is really frightening!

I have had corizone shots before, once for my knee & another for a neck pain that I could not get rid off. They never took me off the coumadin, not even for a day, so please, challenge this & tell your doctor you prefer not to be taken off!

P.S. I have 2 mechanical valves -- Aortic & mitral

 

[Ross]

Not for 5 days without a bridge of some sort. Is the cortisone going into the spine? Unless it's going directly into your spine there is no reason to take you off at all.

 

[witzkeyman]

everybody thought my cardio was crazy when he suspended my Coumadin for 3 days when my INR was 4.4. as my cardio has said before which is highly refuted in these forums, a stroke cannot happen because your INR is very low for a week, it's over a longer period of time I'd say ask your cardio. my cardio has been doing this for 30 something years, so I trust him.

 

[ALCapshaw2]

everybody thought my cardio was crazy when he suspended my Coumadin for 3 days when my INR was 4.4. as my cardio has said before which is highly refuted in these forums, a stroke cannot happen because your INR is very low for a week, it's over a longer period of time I'd say ask your cardio. my cardio has been doing this for 30 something years, so I trust him.

Witzkeyman -

When was the last time your Cardiologist read the CHEST Guidelines for AntiCoagulation Management? or attended an AntiCoagulation Continuing Education Class?

It appears to me that the guidelines have changed considerably since then based on what you have conveyed of his recommendations.

CURRENT GUIDELINES for an INR of 4.4 are to Hold for NO MORE Than ONE Day (or use 1/2 Dose for ONE Day) and return to your Normal Dosing Schedule the Next Day, testing in 4 to 7 days.

According to one of the (Very Well Trained) Certified Registered Nurse Practicioneers at my Coumadin Clinic, it can be argued that for patients whose Primary Diagnosis is Atrial Fibrilation, clotting does take longer than for patients that have Mechanical Heart Valves.

MY interpretation is that Patients with Mechanical Heart Valves should be anticoagulated as soon as the Bleeding Risk drops below the Stroke Risk. Again, MY interpretation is that this is typically in 1 or 2? days following procedures.

 

[Ross]

everybody thought my cardio was crazy when he suspended my Coumadin for 3 days when my INR was 4.4. as my cardio has said before which is highly refuted in these forums, a stroke cannot happen because your INR is very low for a week, it's over a longer period of time I'd say ask your cardio. my cardio has been doing this for 30 something years, so I trust him.

I'm going to have to insist that you stop posting this. It is wrong and it is dangerous. I do not want a new person walking in reading this and thinking it's fine, because it is not fine.

 

[Alistair]

I'm going to have to insist that you stop posting this. It is wrong and it is dangerous. I do not want a new person walking in reading this and thinking it's fine, because it is not fine.

Had I not read Dick0236's story of his three day fishing trip forgetting his Coumadin, I might would have thought the same. Should an INR reading become higher than the goal, would skipping one day or half dose be enough to correct the situation?

Who best determines the risk vs. benefits regarding Coumadin cessation for whatever reason? Your Cardiologist, GP? I'm afraid of regarding Coumadin usage either too lightly or with an over exaggerated sense of urgency. I suppose one is just as bad as the other.

On the off chance that I went to bed without taking my Coumadin, would remembering the next morning and taking it promptly be sufficient or would that also warrant a phone call to the Doctor?

-Alistair

 

[Ross]

Ideally you want to stay in your range. It's not always possible, but it's much better to be too high then too low. You can replace blood cells, you can't replace brain cells.

As far as skipping doses or halfing them, it depends on just how high you are. Never hold a dose for an INR of 4-4.5. Simply half dose one night and resume normal schedule and test in 4 days to see where you are. Al Lodwick has an algorithm chart that explains what to do in most all situations. You can order one from him for $5. Best money you'll spend.

Your cardiologist should be the go to guy. Now if he doesn't understand Coumadin, then there are going to be problems. Very seldom is there a reason to stop Coumadin.

If you forget a dose, break it up over the next two days and take it with your regular dose or simply forget it and continue with your schedule. It all works out in the end.

 

[KristyW]

Had I not read Dick0236's story of his three day fishing trip forgetting his Coumadin, I might would have thought the same. Should an INR reading become higher than the goal, would skipping one day or half dose be enough to correct the situation?

Who best determines the risk vs. benefits regarding Coumadin cessation for whatever reason? Your Cardiologist, GP? I'm afraid of regarding Coumadin usage either too lightly or with an over exaggerated sense of urgency. I suppose one is just as bad as the other.

On the off chance that I went to bed without taking my Coumadin, would remembering the next morning and taking it promptly be sufficient or would that also warrant a phone call to the Doctor?

-Alistair

Alistair,

Our own recognized anticoagulation expert, Al Lodwick, likens the "without coumadin" issue like this..."yes, you can stop your coumadin/warfarin for simple procedures and your INR will drop quickly in most cases. Many people fare ok. However, we must think about it like walking across the interstate. Eventually, you're going to get hit, and how many of us are willing to risk that?"

There isn't one of us that has been on this drug for any length of time that hasn't forgotten to take our meds at least once. It is a slow acting drug, for the most part, so taking the forgotten dose when you remember it is ok. BUT sustained withholding of the drug (3-5 or more days) REQUIRES some sort of bridge or interim measure.

 

[csutherland]

Hmmm...This is interesting. Two weeks ago Jerry's INR was 4.1, normal range is 2.5 - 3.5; he had been on Levaquin 500mg for a few days for pneumonia. He goes to a coumadin clinic and they didn't change anything, but had him come back in a week. In the meantime his pneumonia wasn't resolving so the GP upped the antibiotic to 750mg and added Prednisone. That next week his INR was 6.1. He said the coumadin person studied it for some time and decided to stop it completely for 2 days then pretty much back to the original dosage. (Or maybe there was a .25mg difference one other day in that time.) He goes back Thurs to be checked again. Apparently cortisone really affects INR.

Like you folks, we've always been more frightened of clots than bleeds but his INR had never been this high before. I'm hoping that it's back to normal this week. He's been off all the pneumonia meds for almost a week.

 

[KristyW]

Hmmm...

Like you folks, we've always been more frightened of clots than bleeds but his INR had never been this high before. I'm hoping that it's back to normal this week. He's been off all the pneumonia meds for almost a week.

Celia,
It appears that your ACT folks know what they're doing. They didn't panic at the 4.1, just waited. When the 6.1 hit, what they did seems reasonable, "hold 2 days while the added meds cleared his system and then return to normal". I've never had to deal with prednisone so I don't know how that affects the system. I personally would have held only one day, but the 2 days isn't unreasonable in this case.

 

[Ross]

Even at 6.1 bleeding incident would be rare.

 

[dick0236]

I tend to agree with Ross on this. In my past, doctors had tended to over react to INR hi/lo numbers and would cause my numbers to yo-yo. My current PCP and I agree that warfarin changes be small and infrequent. I have stayed pretty consistent over the years, but "blips" do occur. It could be a testing error, diet, life style or simply a "gremlin". For me, if I go above 4.0 (infrequent) or below 2.0 (very, very seldom), I will hold/increase by ONE dose and retest in 5-7 days. If I am a little below, or above, my range (2.5-3.5) over a couple of test I might make 1/2 dose adjustment.

I have had a bad experience in which warfarin probably played a role and my bad judgement certainly played a role. I try to be consistent with dosing but I am not paranoid concerning this medication. Warfarin usage only requires common sense. I try never to say "never", but I would NEVER allow my doctor to withhold warfarin for even a couple days to adjust INR, unless something way out of the ordinary had occured.

Duh !!!, thats my story and I'm stickin' to it.

 

[Ross]

Hmmm...This is interesting. Two weeks ago Jerry's INR was 4.1, normal range is 2.5 - 3.5; he had been on Levaquin 500mg for a few days for pneumonia. He goes to a coumadin clinic and they didn't change anything, but had him come back in a week. In the meantime his pneumonia wasn't resolving so the GP upped the antibiotic to 750mg and added Prednisone. That next week his INR was 6.1. He said the coumadin person studied it for some time and decided to stop it completely for 2 days then pretty much back to the original dosage. (Or maybe there was a .25mg difference one other day in that time.) He goes back Thurs to be checked again. Apparently cortisone really affects INR.

Like you folks, we've always been more frightened of clots than bleeds but his INR had never been this high before. I'm hoping that it's back to normal this week. He's been off all the pneumonia meds for almost a week.

Actually most clinics would have tested him 3 days after starting Levaquin because it's known to cause the INR to rise and rise fast. Prednisone may cause it to rise also, but the studies are poor in that respect. There are only two that exist.

http://www.warfarinfo.com/levofloxacin.htm

 

[Guest]

It depends on where the injection is going to be. If it is an epidural you MUST be off warfarin until your INR is below 1.2. AND you must be off Lovenox (or similar) for at least 24 hours. The reason is that injecting into the spinal cord while anticoagulated can cause a bleed in the spinal cord resulting in paralysis and likely death. I was a consultant on a lawsuit where a doctor gave an epidural injection to a woman with an INR of 3.9 and it lead directly to her death.

 

[lance]

24-hour Lovenox clearance

24-hour Lovenox clearance

Until now I thought Lovenox cleared the system in 12 hours making surgery safe. I was assured it did and that a spinal would then be perfectly safe.

I'd never had a needle in my spine and opted for a general. I'm glad I did.

Thanks for the heads up Al.

 

[Guest]

The new Chest guidelines emphasize preventing bleeding. They don't directly address these epidural injections, but they recommend holding Lovenox for 24 hours before procedures and that the last dose be only 50% of usual dose.

While an epidural can be an alternative to general anesthesia, they are also done in doctor's offices for people who have severe back pain.

 

[greg]

Tom, like others before, I'd sure suggest not being off coumadin unless the injection was in to the spine. I've had injections in my knee (and fluid drawn off with larger dia. needles) without incident.
Additionally:
Just discussed knee replacement with my cardio. He says off coumadin and bridge with lovenox for 3 days, then the night before surgery skip one lovenox dose. Start right back on coumadin after surgery completed.
This made sense to me....except I'm still delaying the inevitaqble. I'm chicken.

 

[witzkeyman]

I'll stop posting it. no problem. meanwhile, I still have the same cardio. I disagreed with him also, and that's when he gave me the I've been doing this 30 years speech, and are you a doctor?. no problem with not bringing it up again. I actually disagree with my cardio and agree with what I've read on this site. it makes more sense.