Going off Coumadin

[ALCapshaw2]

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.

I'm not sure what you are refering to in regard to your comment about "flaming". If that was construed from any of my comments, please know that was NOT my intent.

When I had an upper endoscopy and colonoscopy, my GI Doc INSISTED that I go off Coumadin. My Cardiologist and Coumadin Clinic recommended Lovenox Bridging which was managed by the Coumadin Clinic to MINIMIZE my risk / exposure. I was fully aware that I was at risk for about 24 hours (but NOT 5 days). We are in agreement on this issue, I just didn't address it in my previous comments.

My understanding of Lovenox dosing also agrees with your statement, 1 mg of Lovenox per Kilogram of body weight. Note that 1 kg = 2.2 lbs. so a 220 lb. person would take 100 mg of Lovenox every 12 hours. I was told to discontine the Lovenox 24 hours before my procedure and resume the night after the procedure, along with a tapered 'loading' schedule of Coumadin.

My comment about letting the experts manage the Coumadin and Lovenox Bridging has both a medical and legal basis. I would assume that any patient who does NOT follow his Doctor's orders absolves that Doctor from any responsibility if something goes wrong and the patient would be considered to be "NON-Compliant".

FWIW, I also agree with the comments from Tommy.

Randy, if you do not have confidence in your Cardiologist, you need to find one who inspires confidence. I also wonder who is overseeing your Coumadin Management.

Many of us have found that dedicated Coumadin Clinics seem to do this best and Good Cardiologists often refer their patients to such clinics. This relieves the Cardio from what I suspect he would consider to be a routine maintenance issue while ensuring proper and knowledgable care, i.e., a WIN-WIN situation for patient and physician.

Bottom Line:

Do NOT self dose Lovenox for this procedure.
Get proper medical management and authorization
that is agreed to by a Cardiologist and the Surgeon.

'AL Capshaw'

 

[PJmomrunner]

Just For the Record...

Just For the Record...

There was a post by a well-intentioned poster that could be construed as rather inflammatory. It was removed.

 

[Nancy]

Agree wholeheartedly with Al Capshaw regarding not dosing yourself with Lovenox or Fragmin. This is too tricky a thing to try to do yourself. No one wants to end up with a stroke due to poor management.

 

[ccrawford]

Only a couple of things I might add. First is that it doesn't hurt to know how to compute the dose for lovenox just to check your doc's computations. I had a dvt last year and the ER doc wrote the prescription wrong, giving me twice the dosage needed. If I hadn't checked it, I would have been in trouble. Secondly, check out the thread called "questions for Al" that deals with an expression of risk from being off Coumidin. The risk isn't as high I as first thought, but still enough to try to always opt for bridge therapy.

 

[geebee]

There was a post by a well-intentioned poster that could be construed as rather inflammatory. It was removed.

Thanks PJ as I was also wondering what Dr. Allan meant by "flaming". I must have missed that post.

 

[bvdr]

I just wanted to add that the morning of my cervical epidural the doc had blood drawn to document that my INR was at or below 1.

I think I was off coumadin for 5 days before the procedure. My INR was out of range and quite high when I went off and I was pleased about that since it reduced the time I was below my range. If there is a next time my PCP said he wants me on IV heparin and I agree. I didn't like how exposed I felt.

 

[RandyL]

Well I hate to write this but I will. I made the appt with my Cardiologist as recommended by most here and saw him today.he did a 3 month check-up, the usual, listened to my heart and did an EKG. Everything fine. I asked him about my procedure, coumadin, lovenox bridging, and so on. His answer was for me to only stay off coumadin as little time was necessary. When I started asking him about bridging on Lovenox he said let me call the Doctor at the lab and see what he says. I sat there and waited for him to call and consult with the lab Doc. He came back to me and said I had to go off the coumadin 5 days before the procedure and there would be no Lovenox bridge. I asked him what about after the procedure, do I start coumadin right away, what should my dose be,what about Lovenox bridge while my coumadin was working its way toward therapeutic? His answer was ask the Doctor at the lab how to proceed after the procedure. As you can see I am not getting much help from my Cardio but I guess I will take his advice and not bridge with Lovenox since I don't know how to do this on my own. When I go for the procedure I will ask the lab Doctor how to continue my coumadin like my Cardiologist told me to.

 

[Christine]

I'm still not crazy about the 5 days off coumadin - if I read it correctly, without any heperin or otherwise? when I had scheduled a colonoscopy few years back.. they had me go off for 3 or 4 days, but I also was on heperin shots twice a day leading up to the procedure.. ended up not having it as I landed in the ER the day before for a totally unrelated issue other then low INR. - allergic reaction to an iron infusion I had that day..

my INR was around a 1 then, which is where it needed to be for the procedure, but until the nite before, I was at least bridging with heperin .. once back on coumadin.. i didn't take the shots, just a dose and a half to start and went from there..

good luck

Chris

 

[Granbonny]

Randy

Randy

I just wanted to say.. I'm sure you will be fine..Try not to worry about being off coumadin ..Have your procedure monday..and then your coumadin again.... I'm sure the doctor doing the procedure will tell you what mg. to start back on......May take a few days to get back in range. Just watch the Vit.K intake.....Like I said, I'm sure you will be fine and hope this helps with your back...Bonnie

 

[Ross]

Ross,

I tried to respond to Randy L's last post regarding the response from his cardio but AOL kicked me off VR.com with a note that I needed to upgrade my Browser. (I know, but the dialup download is almost 2 hours and yada yada yada).and that my browser was not capable of reading the content of that site.

Could you post the following to Randy L for me?
IMHO, his Cardio is putting him at HIGH RISK with the recommendations outlined by Randy

----------------------

WOW Randy, no wonder you have no confidence in your cardiologist!

Please tell us, WHO is managing your Coumadin and monitoring your INR?

I can't help but get the impression your current Cardiologist is not comfortable managing Coumadin OR Lovenox and does not want to be responsible for the outcome, hence his suggestion that the (non-cardiac) Surgeon manage your Coumadin for the procedure.

If I were in your place, I would find ANOTHER Cardiologist ASAP, one who understands how to manage Coumadin and Bridging Therapy and who understands (and appreciates) the RISK of not being anticoagulated for several days.

'AL Capshaw'

 

[RandyL]

Thanks Ross

And Thanks again for the millionth time AL.

To answer your question I am monitoring my own INR based on your chart you sent me. I have a home test and it seems to be working great. I have been in my range for 6 weeks now and have not had to change my dose at all.I test every week at the same time.

I will have to stick with what the Cardio and Lab Doc has advised for now. I would however like to know what your advice is after the procedure since my Cardio just said to ask the lab Doc. I have checked into getting a new Cardio that has a coumadin clinic in his group. But for now would like your opinion if you don't mind.
Thanks

 

[DrAllan]

Randy,

It is obvious to me that your cardio neither is knowledgeable about Coumadin or interested in learning or treating your properly. Now what does it mean about ?calling the lab doctor?? Diagnostic laboratories are run by pathologists, who may very well be very knowledgeable about the tests, the indications and what the results mean. They may be very aware of what confounds the testing. They are not very likely to be knowledgeable about treatment protocols except to the extent that they see abnormal lab results and may inquire or be informed as to the factors leading up to these abnormalities. Regardless, this was an informal consultation between physicians; you are not a patient of the ?lab doctor?. Your chances of finding this person and talking to him are practically zero. If anything your cardio, in his ignorance of anticoagulation, should have been seeking the advice of a hematologist (doctor who specializes in diseases of the blood system), or a certified coagulation expert such as our own ?Al? on this site. You have been denied proper preoperative e advice and care and have no one giving you postoperative care. Except for you self-dosing your own Coumadin trying to use your remaining 5 Lovenox is inadequate for both the preoperative and postoperative time periods. The fact that you have 5 syringes of Lovenox left over from your surgery is tempting to use but dangerous without supervision.

My advice at this point is to print our all of the responses to this thread, put them in an envelope for your next-of-kin or responsible care giver to use to sue the incompetents caring for you if disaster strikes.

This answer is not intended as and does not substitute for medical advice - the information presented is for patient education only. Please see your personal physician for further evaluation of your individual case.

 

[RandyL]

Dr. Allen,

I appreciate your direct approach. I have a call into my Surgeon to get his opinion and direction. I will most definately change Cardiologists. If my surgeon says to go ahead with the procedure without bridging then that is what I will do. If he says to definately bridge then I will reschedule my procedure and seek out a new Cardiologist. Thank you for taking the time to answer my questions. BTW the lab Doctor is a neuroradiologist.

 

[ALCapshaw2]

Dr. Allen,

I appreciate your direct approach. I have a call into my Surgeon to get his opinion and direction. I will most definately change Cardiologists. If my surgeon says to go ahead with the procedure without bridging then that is what I will do. If he says to definately bridge then I will reschedule my procedure and seek out a new Cardiologist. Thank you for taking the time to answer my questions. BTW the lab Doctor is a neuroradiologist.

Randy,

I can't help but be VERY concerned about proceeding without consulting *someone* who understands and appreciates the SIGNIFICANT RISK of STROKE when you are NOT anticoagulated. Most NON-Cardiac Doctors / Surgeons are more concerned about the Risk of Bleeding than the very significant risk of STROKE, hence their advice to go OFF Coumadin for 5 days. As far as they are concerned, if you have a STROKE, that is YOUR problem for which you will consult someone ELSE.

Taking this VERY BAD advice and "throwing your fate to the wind" scares the H*** out of me. Since my GI Doc refused to do my Upper Endoscopy and Colonoscopy while anti-coagulated, my Cardiologist recommended Bridging Therapy to be administered and monitored by the Hospital's Coumadin Clinic CRNP. The GI Doc concurred with this approach and all went well.

Are you familiar with the cases on VR.com where one or two patients suffered PERMANENTLY DISABLING STROKES while OFF their Coumadin for routine Colonoscopies? I've forgotten their name(s) but I'm sure you can find the posts and followup, including a copy of the LAWSUIT filed against one of the Doctors for negligence.

BTW, AL Lodwick is the our resident Coumadin Clinic Director (from Colorado).

'AL Capshaw' (just another AVR patient and mechanical valve recipient who takes Coumadin)

 

[ALCapshaw2]

Thanks Ross

And Thanks again for the millionth time AL.

To answer your question I am monitoring my own INR based on your chart you sent me. I have a home test and it seems to be working great. I have been in my range for 6 weeks now and have not had to change my dose at all.I test every week at the same time.

I will have to stick with what the Cardio and Lab Doc has advised for now. I would however like to know what your advice is after the procedure since my Cardio just said to ask the lab Doc. I have checked into getting a new Cardio that has a coumadin clinic in his group. But for now would like your opinion if you don't mind.
Thanks

MOST people who home test have *some* Doctor or Clinic that monitors their INR (you call in the measurement from your home test machine and they tell you if you should make any changes, or at least record your input for their records).

Do you have a Primary Care Physician?

If so, have you advised your PCP of the recommendations you have received from your Cardiologist and Surgeon?

It is the job of the PCP to look out for YOUR best interests and coordinate all your 'other' doctors / specialists to be sure everyone is on the same page. Perhaps your PCP can find you a more supportive Cardiologist who will take a more proactive interest in your Coumadin / INR monitoring and management.

If I were in your shoes, I'd postpone the procedure until you get a second opinion, hopefully from someone who understands the benefit of Bridging Therapy and how to bring your INR back following the procedure. You should NOT be doing that on your own.

'AL Capshaw' (the AVR patient, NOT the Coumadin Clinic Director who is Al Lodwick)

 

[Georgia]

I've been waiting to see what others have said.

Now, my two cents:

When I had a herniated disc the excellent back surgeon I saw said I'd have to be in a wheelchair before he'd do an epidural b/c of the risk of stroke from going off coumadin. I was sent to pt and eventually the disc healed itself.

I KNOW how bad the pain is. It nearly drove me crazy. But I don't think the risk of being off coumadin without bridging therapy is worth the relief you may get from the epidural. I'm with Al; I'd delay the procedure.

But whatever, best of luck and hope this gets straightened out.

 

[Guest]

When I am consulted about restarting warfarin, I say that when the surgeon thinks that there is little risk of bleeding, start warfarin that night at the same dose as prior to surgery. Since it takes about 3 days for it to start building back up, it poses little risk of causing bleeding. Due to diet and exercise concerns the dose of warfarin may be less than it was before surgery, but using the same dose gives a good starting point.

 

[Consuela]

Going off Coumandin

Going off Coumandin

I, too, have been told to go off coumandin while I have a biopsy of two cysts in my thyroid. I hesitate to do this, so I called my surgeon and asked the best way to go about it. My PCP first said go off coumandin for a week and then said make it three days prior and then have the procedure and then wait 24 hours and then resume. It sounded like he wasn't sure and then proceeded to tell me that it was dangerous. I walked out of his office more confused than ever.
I spoke to the surgeon who gave me my St. Jude Mechanical Valve on December 14th of last year, and he said that the best way to do this is to have an IV drip of Heparin and the procedure done in the hospital.
It seems that the doctors handle this like a hot potato. No one wants to get involved.

 

[Guest]

One of the big reasons that doctors are confused is that there are no good studies that provide guidance on what to do. Mechanical valves are not hot political topics like AIDs so there is little federal funding. Heparin is generic and dirt cheap so no company is going to profit from such a study. The result is that nobody is sure of what to do. If you posted a poll on here and asked how many have mechanical valves and had a thyroid biopsy there would be very few responders. So it is unlikely that even one doctor has ever handled two cases. While "in my experience" is the lowest grade of proof, it is unlikely that you can find a doctor who even can say that. This is why this forum provides such valuable information. If anyone else on here has ever had it done, you can be sure that you will get a response.

 

[Consuela]

getting off coumandin while I have a biopsy

getting off coumandin while I have a biopsy

I got the answer I want. asked the surgeon that gave me my mechanical heart valve and he told me that I would go off the coumandin and go to the hospital for the heparin drip and they would do the biopsy of the thyroid cysts and then I would resume the coumandin the following day. He also said that Lovenox was NOT FDA approved.