Going off warfarin for 5 days. Scared!

[Robt Z]

I am having outpatient surgery to remove a lipoma from my rib area. Doctor wants me off warfarin for 5 days. I have a metallic valve. I am scared to be off warfarin. What if I have a blood clot or stroke? Any advice from fellow metallic valve recipients will be helpful. Thanks Robt Z

 

[LUVMyBirman]

Hi Robert,

You should not have to be off your Coumadin that long. Do you know how long it takes your levels to come down? Average person 36 hours. Myself, 24 hours. Missing one dose and I am down in the 1's.

This is the way I would be handled by my physcian. 24 hours prior to the proceedure I would be admitted. 24 hours prior to arriving I would hold my Coumadin. (In your case maybe 36 hours). Your INR could then be checked (prior to admitting) then you would be be hooked up to the IV Heparin. That way you are still covered. 12 hours before the proceedure they would stop the Heparin. This leaving a window of 12+ time in surgery. Lets just say 24 hours uncovered vrs. 5 days. Proceeding surgery they can start the IV again. Resume Coumadin the next day along with the Heparin until level is up. I usually plan on 10-14 days from start to finish. One of the reasons I have been putting off the "female" operation I need. I am pretty miserable...but it's not life threatening. Just can't squeeze in a 2 week hospital stay at this time of year. Maybe in the fall

Hope I have not lost you. All the best.

 

[Nancy]

That is way too long to be off Coumadin. You should be going into the hospital and be given a Heparin drip, and then be kept in the hospital until your INR gets to therapeutic levels.

You have every reason to be afraid.

Does your cardiologist (or monitoring doctor) know about this??? You should have a cardiologist (or other monitoring doctor) monitoring your Coumadin and Heparin. Although other doctors know a little about Coumadin, your cardiologist (or other doctor who is monitoring your anticoagulation) is the one who should be taking care of the proper anticoagulation protocol.

There are very specific protocols for the proper procedure for surgery.

 

[Rain]

I?d freak out too, Robert.

I?d freak out too, Robert.

Because of atrial fibrillation I was on coumadin prior to open heart surgery. The surgeon told me to stop taking it the Friday before my surgery the following Tuesday morning.

The surgeon had an emergency, so I ended up having the surgery Wednesday. So in the end I was off of it for five days. Anyway, the point is.... I wouldn?t think you would need to be off of it longer than I was to have OHS?!

I hope you're talking it over with your cardio!

 

[Marty]

Surgeon has tunnel vision

Surgeon has tunnel vision

Robert, I'm afraid your surgeon has tunnel vision. When he looks at you he only sees a lipoma. I'll tell you this, as far as I know, a lipoma has never killed any one. You've got time. I personally would get another surgeon. If you were referred to this surgeon by your PCP talk to him about it. Our warfarin guru , Al Lodwick has a patient who was taken off anticoagulants so a gastroenterologist could go after a tiny colon polyp. This lady did stroke.

 

[Rich]

Robert,
Five days is just not realistic at all.
It sounds like this guy just doesn't want to be bothered by it.
You definitely need other therapy such as heparin.
I had a doctor tell me something like that for surgery he wanted to do on me.He had no clue what to do except have me stop the Coumadin.
I found another doctor !

 

[Robt Z]

Now I am really worried!!

Now I am really worried!!

I will call cardiologist and avr surgeon tomorrow to ask them for advice. I want this lipoma cut out. It is growing and I cant stand it anymore. The general surgeon will do it in his office next week. He thinks inr should be 1.0. It is my internist who said to go off warfarin for 5 days prior. I dunno what the heck to do now. Will make some calls in the a.m. Has anyone went off warfarin for 5 days without any problem? Do you think I need to go into a hospital for the simple surgery? ? Thanks. Robt Z

 

[ALCapshaw2]

I believe there is another alternative - Lovenox injections,
which I also believe you can give yourself, assuming you
are comfortable with this idea. Ask your doc's about this
alternative.

YES, being on Coumadin DOES complicate invasive procedures. That's one of it's downsides. As you have become aware, a simple day surgery can turn into a weeklong 'event'. Bummer.

'AL'

 

[JimL]

I have asked a similar question regarding having a cyst removed. A surgeon would have put me on Lovenox. My cardiologist was a little more up on the subject, and knew that that was no longer the official recommendation; he suggested I plan on a week in the hospital for what should be a simple outpatient surgery: three days on heparin for my INR to drop, and three days after surgery for my INR to rise again. I don't have that kind of time until the middle of the summer, and maybe not then.

Al Lodwick gave me the following reference:

I just found this. Give your doctor this reference.

Kovich, O. Thrombotic complications related to discontinuation of warfarin and aspirin therapy perioperatively for cutaneous operation. J m Acad Dermatol 2003 Feb;48 (2 Pt 2):233-237 (any librarian can look this up)

The authors are from Mayo Clinic in Rochester, Minnesota. They found (in a poll of 168 doctors) that when warfarin was withheld before skin surgery the risk of a clot doubled from 1 in 13,000 to 1 in 6,000. The clotting events were strokes, heart attacks, TIAs, DVT, PE, 1 clot in the eye leading to blindness and 3 deaths.

There was no increase in severe bleeding complications.

The authors call this, "a compelling argument to keep patients on medically necessary blood thinners during cutaneous operation."

I'm still looking for a surgeon to do the outpatient surgery on me. I've come to the realization that it is well worth it to travel a ways to find such a surgeon.

 

[Nancy]

RobtZ-

It really doesn't matter if others have been off Coumadin and had no problems. If YOU go off Coumadin, and have a blood clot incident, worst case scenario, stroke or even death, then it is a terrible tragedy for you and your family. It's not worth the risk, when there is already in place a safe protocol for doing this, and the vast percentage of Coumadin monitors know how to do it properly.

There is a relatively new FDA directive against using Lovenox injections for heart valve recipients. It is back to the time honored in-hospital Heparin drip.

There is some controversy about this directive, but that is the way it stands for now, as far as I know.

Please take the safe road in this case. I'm sure your doctors will get it done the right way for you.

 

[cookie]

Lovenox

Lovenox

Hi Nancy!
What is being said about Lovenox injections? Both my PCP & anti-coagulation Pharmicist are saying to take Lovenox for a colonoscopy coming up. It's out patient and I certainly don't want to stay in the hospital for such a minor test!

 

[Kim]

I, too, have an upcoming colonoscopy appointment and my doctor says to use lovenox in the interim. I wonder what Al recommends?

My daughter who graduates in 2 weeks (yeah!!) with a PharmD, feels it is still a great anticoagulant to use when you have to be off Coumadin.

 

[LUVMyBirman]

Hi Cookie,

Try this link. Most doctors will not prescribe. Though, you are of the few I have seen posts from that it continues. There is a lot of CYA going on in the medical community. My doctors forbid it. Dreading the day I really need to come off my Coumadin for something. It takes weeks for my levels to resume.
Have you heard of the virtual colonscopy?

PS. I did ask about injectable Heparin last week. And receicved a yes. Weather that means yes I can use it, not sure.


http://www.fda.gov/medwatch/SAFETY/2002/lovenox.htm

 

[Nancy]

Cookie and Kim-

I guess it's something you will have to take up with your doctors. All I can tell you is that the directive from the FDA exists and is worded emphatically. The link Gina gave tells it all.

There are medical people who are trying to get it reconsidered, but haven't heard anything on that yet.

Maybe Al would comment.

 

[sylviayasgur]

hi all!
robtz,
i agree with nancy.... i always try to be conservative when it comes to joey's health and heart. it's not worth the risk to me/us.
i would seriously chek into this.

nancy,
i , too, would love to hear from al lodwick. when my dad had his chf and was hospitalized in fla. a few months ago, his coumadin levels were really low. they gave him lovenox shots and i totally freaked out because i had heard/read (maybe here) that they were contraindicated for those patients with mechanical valves (?).
his cardiologist there said it was ok and the benefits out-weighed the risks..... i'm not sure i would agree with him, but he's the one my dad listens to.

this is a scary thing. i often wonder what you folks do in terms of coumadin, when you have to have procedures done.

hoping this all works out well.

robtz, please let us know what happens.
be well all, sylvia

 

[Nancy]

I don't know, but if the FDA has written a directive like that, if I were in the medical profession, I would adhere to it. It leaves you open for some serious criticism, especially if something were to happen. If there is something else that can be done and it is safer, it's probably the way to go. I know there are other opinions, because it has been discussed here many times. Maybe if you do a search on Lovenox, it would bring up the discussion. It has to be within the last year. That's approximately when things were changed.

Joe has had surgery both ways, one of them heart surgery.

I'm sure the insurance companies are looking for some further investigation.

 

[ShezaGirlie]

Cookie, Kim & RobertZ

Cookie, Kim & RobertZ

Cookie & Kim .. Virtual Colonoscopy = staying on Coumadin and NO drugs.

RobertZ .. I would be looking for a new Internist.

 

[Guest]

RobtZ wrote to me and I directed him to this site.

I recommend Lovenox because it is so much more convenient for patients. There is probably more evidence that it is safe and effective than there is for heparin drips.

Many of us in the field think that the FDA made a completely irrational decision when they put the warning on Lovenox.

I have a form that I drew up that I send to doctors who ask about this. It tells them what to discuss with the patient so that an informed consent can be made. It tells the patient that the FDA recommends against this but that they have no other convenient alternative.

To read my thoughts please look at http://www.warfarinfo.com/bridgetherapy.htm

 

[Nancy]

Hi Al-

Seems like a reasonable thing to do. You always have good solutions.

 

[LUVMyBirman]

I used Lovenox many many times. For weeks on end with great success when coming off the Coumadin for misc procedures.

As Al stated it is most likely a MAJOR overreaction by the medical community.

Do I agree with the FDA? No. Will I look around for another physcian out of convenience that will prescribe me Lovenox? No. I think with something this serious we should just give in to the Heparin drip. Long hospital stays stink. In comparison to a stroke or worse it's not a half bad option.