Going off Coumadin

[RandyL]

I will be stopping my coumadin on June 1st to have an epidural procedure June 5th. I plan on starting my coumadin right after the procedure unless someone here says different. Do I go back to my normal dosage of 10mg per day or do I take more at first. I also have 5 Lovenox injections leftover from coming home after surgery. They are 60mg shots. Should I take them also? Looking for some advice. Thanks

 

[Ross]

Randy I'm going to leave this one for Al. Epidurals are not the ones for me to answer on. He may be a bit getting here, but please be patient or PM or Email him about it.

 

[JimL]

I've had three cysts removed since I went on coumadin for life -- I'm not sure if that's the same kind of surgery you're having or not. I searched and found a doctor who would do the surgeries while I stayed on coumadin. The first I had general anesthetic, the last two just local. I had no problems at all on the bleeding front.
If it would help, I could share the doctor's name and phone; perhaps he can recommend someone in your area. PM me.

 

[Lynlw]

with epidurals the problem is even a drop of blood could paralyze you. randy you have been in my prayers, I know how awful back pain is and you've been dealing w/ this for a while now, I hope it brings some relief, Lyn

 

[RandyL]

Thank you Lynn

Jim I am geting a epidural steroid shot for my back pain. I have a herniated disc at L4 and the chiropractors have not been able to help me so this is the next step. If this doesn't work than I am researching the lazer back surgery they have now.

Ross I question is really about coumadin. I already know the risks of the epidural, I just need some advice on how to handle my coumadin.

 

[Lynlw]

I have one of these implanted, http://www.ans-medical.com/patient/basicsofscs/index.cfm

honestly it really doesn't help much but worked well the first couple years, but i don't know if they could put on in a patient on coumadin, lyn

 

[bvdr]

I will be stopping my coumadin on June 1st to have an epidural procedure June 5th. I plan on starting my coumadin right after the procedure unless someone here says different. Do I go back to my normal dosage of 10mg per day or do I take more at first. I also have 5 Lovenox injections leftover from coming home after surgery. They are 60mg shots. Should I take them also? Looking for some advice. Thanks

Follow your doctor's instructions. When I had my cervical epidural I started my coumadin that night and I think used the first Lovenox after 12 hours. I have read that loading doses of coumadin are not really used much anymore. Your doc will probably have you start back at your regular dose and by the time your lovenox are finished you should be good to go. Do find out how your doc wants to handle this though and this isn't like having most procedures since bleeding in this case can be really serious. I hope you get good results with your epidural.

 

[ALCapshaw2]

Talk to your CARDIOLOGIST, ASAP.

Ask if your REALLY need to go OFF Coumadin for this procedure.

Then ask if you should go on BRIDGING THERAPY (Lovenox) while you are off Coumadin. Whoever manages your Coumadin should also be able to manage the Lovenox protocol.

Bottom Line: Let the PRO's call the 'shots'!

'AL Capshaw'

 

[RandyL]

Talk to your CARDIOLOGIST, ASAP.

Ask if your REALLY need to go OFF Coumadin for this procedure.

Then ask if you should go on BRIDGING THERAPY (Lovenox) while you are off Coumadin. Whoever manages your Coumadin should also be able to manage the Lovenox protocol.

Bottom Line: Let the PRO's call the 'shots'!

'AL Capshaw'

Well Al, the way I see it I am asking the pros. When the lab called my Cardio they gave the instructions of "Stop taking coumadin 5 days before epidural procedure" and those are the only instructions I have. I have little or no faith in my Cardio in regards to coumadin. Every decision his office has ever made concerning coumadin has been wrong. I don't believe he has an understanding of the drug as far as dosing goes because his decisions have not been in line with the experts on this forum. I have Al's chart and I follow it religously and I have been in my range all the time(2.0-3.0) btw which is not what my Cardio wanted. He wanted me to be within 2.0-2.5 which is about as ridicoulous as he not signing off on my home test machine(had to get it through my primary Doctor).

So any advice here is very appreciated since it is the advice I believe in and will follow.I will be going off the coumadin, I just want to know which is the best way to start back up. Like I said in my previous post I do have a prescription for Lovenox from my surgery and could use it after the procedure if you all think I should and also Should I take my normal dose of coumadin the night of the surgery?

Thanks Again.

 

[geebee]

Randy,
I fear for anyone who needs to go off coumadin but I also understand back pain so I feel for you also.
Since the danger of bleeding for the epidural should cease the minute the epidural is over, I should think you can go back on coumadin right after the procedure since it will take a couple of day for you to be back in range. I would also consider lovenox until you are back in range. If the lovenox you have has not expired and you feel you have enough to get you back in range, I do not see any reason not to use up such an expensive drug. However, you should make sure your doctor is aware you are using it. He should also be able to tell you when to start the lovenox.
As far as the amount of coumadin to take after the procedure, I would just take my normal amount as it takes so long to work I don't think doubling would jump start things and it could cause your INR to yo-yo.
Best of luck to you.

 

[PJmomrunner]

However, you should make sure you doctor is aware you are using it.

~Geebee

And now...from the peanut gallery...

I understand that you don't trust your cardio re: coumadin therapy, but I really think you should ask enough questions (particularly of the person doing the epidural) to gain confidence that your ACT is being properly managed so as to avoid both clotting and bleeding problems. Much searching the web and PubMed has turned up lots of uncertainty and controversy regarding ACT and epidural anesthesia.

The info seems to refer to epidurals during surgeries, not for administration of medication for back pain, but it seems that the crucial times for complications (hematoma resulting in spinal compression, etc.) seem to be when the needle is inserted and when it is removed. If I read correctly, care needs to be taken to monitor the level of anticoagulation (INR, etc.) to be sure it is sufficiently low during those times. Of course, before and after those times the main concern would be clotting events due to sub-therapeutic ACT. Every reference states that this is complicated and requires understanding on the part of the team administering the epidural.

Whatever you do, don't do it on your own. As everyone else has said, do involve your medical team. You might want to print off Al's bridging regimen and see if they feel it applies in your situation. (http://www.warfarinfo.com/bridgetherapy.htm) Here's another reference for your info: www.asra.com/Consensus_Conferences/Horlocker3.pdf

All the best to you!

 

[RandyL]

Looks like Al's bridge recipe is 1mg of lovenox every 12 hours. My shots are 60 mg which I took once a day after my surgery waiting for my coumadin to become theraputic. I guess I won't be bridgeing on 60mg before the procedure.

 

[tommy]

Randy,

You have several variables in this discussion. There are enough variables in the medicine and treatments, to add more unnecessarily. Here's how I sort them out. Back pain has got to be the pits - debilitating and demoralizing. Hang in there.

1. If you don't have confidence in your cardiologist, find another one. I don't mean to shop until you find one that you agree with, but you must get excellent care and have confidence of same.

2. IMO you should have professional assistance managing your Coumadin dose.

3. It is not acceptable to simply "go off" anticoagulants without a sound strategy. Every procedure has it's risks that have to be weighed against risk of bleeding and risk of stroke.

4. The doctors need to work together for bridging therapy. My cardio always calls the surgeon to negotiate the strategy. PS, my cardio always prevails.

5. Lovenox is dosed by body weight. I'm not sure where your 1 mg suggested dose came from. My dose is typically 90-100 mg.

6. Lovenox is administered every 12 hours because that's about how long it dissipates. If your procedure gets riskier because of bleeding, the docs may want you to stop Lovenox more than 12 hours prior to the procedure. See #4.

I wish you well. I'm concerned that your plan is not well thought out. Can you put this off until you get more/better help?

 

[RandyL]

I apologize if I came across wrong. I didnot consider bridgeing because neither the lab Doctors or my Cardio suggested it. Maybe I haven't chosen the right words to explain my situation, I am not trying to be a horses azz. The instructions I got were to stop coumadin 5 days before thew procedure and that was it. All I was trying to find out was how to start my coumadin back up or if I should take some Lovenox shots until I got theraputic on the coumadin. Now I don't know what I am doing to endanger myself other than the risk of being off the coumadin but I don't see anyway around this. Again I apologize if I have offended anyone.

 

[Lynlw]

I know that this doesn't help Randy, but since he first started asking about needing the epidural, and i could be off base here, but.something i have been thinking about alot (as a person w/ a really misserable back) is Maybe when trying to decide what kind of valve to get, somewhere in the discussions along w/ asking women in childbearing years, do you plan on having more children, is do you already have back problems?for most back problems i know it is a lifelong issue and when you are thinking about heart surgery, thinking about your back wouldn't cross my mind, if this hadn't been brought up. I'm certainly NOT saying everyone w/ back problems should get a tissue valve, but I think it should play some part in the thought process. I was wonderring if anyone elsehad thoughts about this, lyn

 

[RandyL]

Lynn, I hear what your saying. Sometimes I look back and think maybe I should of got the tissue valve especially since they seem to be lasting longer and longer. However the mechanical valve is still the best way to go. Coumadin is your friend not your enemy. I have no problem taking coumadin the rest of my life and it has not been a problem keeping the dosage in line so far. I have had a few back problems over the years, nothing a good chiropractor hasn't been able to fix. I didnot have back problems going into surgery, the last back problem was a good 10 years ago. When I woke from my second surgery my left thigh was completely numb and has been since January. It also pinches and burns occasionally throughout the day.After an XRAY and MRI I have a herniated disc that everyone thinks is causing the problem. My back doesn't even hurt. I have had 2 different chiropractors trying to help me with no success. At the suggestion of a orthepedic Doctor I took oral steroids which unfortunately did not work. They then suggested the epidural steroid injection. This is probably the only thing left to try before back surgery or enroll in pain management. I don't like the idea of either one. I still think the mechanical valve is the way to go, it just takes extra precautions to deal with when you have another illness that involves your blood.

 

[DrAllan]

This thread is the closest to ?flaming? that I have seen on this site. I believe that the ?1mg? statement is missing the fact that the dosage recommended by Al is ?one milligram per kilogram of body weight?.

I have the feeling that many at this site think that ?bridging? therapy is some sort of magic cure for being off of Coumadin but still protected by being anticoagulated. This is very far from the truth. A bridge is something that connects or allows passage from one place to another, many times across a river or some such impediment as a river of chasm. Because it takes several days for the effects of Coumadin to dissipate as well as several days for it to become effective when restarted, a heparin product such as Lovenox is used to bridge the time from the stopping point to the completion of surgery and then to the resumption of effective anticoagulation from Coumadin. WHAT IS MISSING in this discussion is that fact that from about 12-14 hours after Lovenox is stopped prior to the surgery until a few hours after it is restarted following surgery (usually 12-24 hours) that you are NOT anticoagulated and at risk of stroke. What the bridging therapy does is reduce this time at risk to a minimum compared to just stopping and restarting Coumadin.

 

[RandyL]

This thread is the closest to ?flaming? that I have seen on this site. I believe that the ?1mg? statement is missing the fact that the dosage recommended by Al is ?one milligram per kilogram of body weight?.

I have the feeling that many at this site think that ?bridging? therapy is some sort of magic cure for being off of Coumadin but still protected by being anticoagulated. This is very far from the truth. A bridge is something that connects or allows passage from one place to another, many times across a river or some such impediment as a river of chasm. Because it takes several days for the effects of Coumadin to dissipate as well as several days for it to become effective when restarted, a heparin product such as Lovenox is used to bridge the time from the stopping point to the completion of surgery and then to the resumption of effective anticoagulation from Coumadin. WHAT IS MISSING in this discussion is that fact that from about 12-14 hours after Lovenox is stopped prior to the surgery until a few hours after it is restarted following surgery (usually 12-24 hours) that you are NOT anticoagulated and at risk of stroke. What the bridging therapy does is reduce this time at risk to a minimum compared to just stopping and restarting Coumadin.

Thankyou, that makes a lot of sense. I will call my Cardiologist tomorrow to see if he wants me to do this. His instructions did not include this bridging procedure. It sounds like I would only be at risk for some hours versus days. Thanks again, I think I understand this now.

 

[RCB]

With all due respect Dr.

This thread is the closest to ?flaming? that I have seen on this site.

If this is your experience, you haven't read much of this site. Check out some of the threads on Valve and Small Talk forums that make this seem polar by comparison.

I have the feeling that many at this site think that ?bridging? therapy is some sort of magic cure for being off of Coumadin but still protected by being anticoagulated. This is very far from the truth. ............. WHAT IS MISSING in this discussion is that fact that from about 12-14 hours after Lovenox is stopped prior to the surgery until a few hours after it is restarted following surgery (usually 12-24 hours) that you are NOT anticoagulated and at risk of stroke. What the bridging therapy does is reduce this time at risk to a minimum compared to just stopping and restarting Coumadin.

Reducing the time is about as close to "magic" as we can expect. No ACT is perfect. People have strokes when fully in their INR range. Tissue valves can be a source of strokes, specially during the end of their life. All one does with bridge therapy is attempt to lower the risk. "lower the risk" is the goal in most medical procedures. In 46 years of ACT, I have had one major stroke(being off warfarin) and no bleeds. Any Dr. who ask me to go off warfarin without some kind of bridge therapy, simply doesn't get my business. Strokes
can make HVR look like a cake walk.

 

[Nancy]

I just want to put in my two cents. Joe has been on anticoagulant therapy for 28 years. It is ABSOLUTELY NOTHING to fool around with. It has to be taken care of with as much thoughtfulness as humanly possible.

During those 28 years, Joe has been off Coumadin and on to bridging therapy numerous times. Minimizing his risks is of utmost importance. So, he will NEVER go without bridging therapy. He cannot take Lovenox or Fragmin due to kidney issues. So he has to go into the hospital several days prior to any procedures, for IV Heparin and then on the back side, he has to stay several days on Heparin until his INR gets into therapeutic range.

During those years he has also had numerous TIAs, splenic infarctions, and a retinal artery occlusion causing blindness in his left eye. Some of these were when he was within his INR range, some were not. They were all clots coming off his valves. He also has afib from time to time, and it is also possible that the afib could have caused some of these clots.

Joe also has bleeding issues in his GI tract. So he has a double edged sword. His INR range has to be as low as possible to keep him from bleeding to death, but high enough to keep clots from forming. It's a very narrow INR range.

So what RCB says is very true. The only thing that can be done is to try to minimize risk. It is very serious business and it has to be done right.