Help, Bridge Help

[djacq]

I got the USUAL, HOLD coumadin FIVE days before my breast needle biopsy Monday at 1pm!!!!

It is an outrageous problem in the medical field. I was not able to get ANYONE, including my own PCP to take this seriously. He told me to do what they said.

My cardio was away, they never called me back anyway to find out who was covering and time was passing before the week end when I felt I would be in a real mess.

At the last minute before he left for vacation, my PCP called as he must have heard about my many phone calls pleading for help.

So, the deal per my PCP: Last dose Coumadin Thurs, Lovenox 2X a day Fri, Sat, Sun, procedure Mon and Mon night Coumadin and Lovenox and Tues just Coumadin. Gave me SEVEN doses!

After reading this phenonemal site, (thank you Tom and Al) I realized I would be unprotected Tues, etc. I panicked, called my most wonderful pharmacy in the world and told them of my fear. They called the PCP for me and asked if he would give me the whole pkg of Lovenox (10). I the figured I would have extra for Tues in case my INR did not go back up right away even if this wasn't the PCP's instruction.

The deal I decided to do per info on VRC was to take last dose of coumadin Thurs and wait for my INR to go down to 2.0 and start Lovenox today, and visa vera after procedure Monday. Having the 10 syringes I would have enough after the procedure to get my INR back up.

BUT, this morning my INR is 3.7 per my Pro Time. Do I still wait until it is 2.0? Time is getting short before Monday's procedure.

Any input would be much appreciated and as an aside, what can we do to develop an awareness to this lethal problem?

If I was not somewhat of a Coumadin savy consumer, I may have stopped the Coumadin as directed for five days. Why do I have to do anything for just a needle biopsy?

At any rate, this has totally consumed my attention and I have had little time to worry about the breast lump or even continue my daily worries and fears for my son in Iraq!

That is the good side.

Thank you for any ideas you may have about what I should do today.

Donna

 

[Ross]

You shouldn't have to be off for this. The insanity is never going to stop with these people. I think I'd wait until your at 2 which may or may not be Monday. I'm not the pro here, so I guess I'll let Al talk about this one.

 

[Nancy]

Donna-

Not going to address the bridging, just let Al do it.

However, when I had my needle biopsy, it was a core needle and pretty darned fat with a spring load on it, so it has the potential of causing some bleeding.

I want to wish you all the best with your biopsy. All the odds are in your favor.

 

[tommy]

Donna,

I'm not up-to speed about the bleeding risk of the needle biopsy. I do wish you well with the test. And the next time you communicate with your son, please thank him for me. Maybe the anticoagulation diversion is theraputic?

You were smart to question your orders and be persistant. Way to go! Your INR seems to be starting from a high place. Not much you can do about it now, huh? I see no need to start Lovenox until you are below INR 2.0. It's your decision. Better to err on the side of protection. The reason for Lovenox is to protect you in place of warfarin. You don't need both.

The doc may hesitate to do the procedure if you INR hasn't dropped far enough. He may want to put it off a day or so. My experieince is that they do this stuff on certain days of the week, and pushing one day may not be in the cards. Again, it's your call if you want to be persistent and push for no delays.

Are you home testing yout INR? If so, you can fine tune when you start the Lovenox and stop it based on the 2.0 INR. If not, testing over the weekend is a pain, and you may not get the instant results that you need to do the fine tuning.

Frankly, stopping Lovenox on Tuesday sounds premature. You know the 2.0 drill on the way up.

Seven doses may very well be enough if you can accurately wait until 2.0 before starting Lovenox. But if it isn't enough, you will pay two co-pays for the two presciptions. Boxes come in qty of 10. Should you decide you need less than (or more than) a box, shop around for a pharmacy that will break up a box. Make a few phone calls. Target does it for me. Walgreens doesn't even stock Lovenox. I saved my excess for the next time. Not wishing a next time on you or anyone.

BTW, what dose are they giving you? You may have seen in my post that my GE and cardio had a "discussion" about the dose. The GE wanted 30-40. the Cardio insisted on 100. The dose is scaled by body weight, so you don't have to answer the question for us on line.

Again, I wish you the best outcome on all fronts.

I'm on a LB right now for colonoscopy on Tuesday. I started from 2.5 and dropped out of range quickly (2 days). I was originally going to get a prescriotion for 5 Lovenoxes (to add to my 3 left over - yes I checked the expriation date), but decided to be safe and get 10. The diversion to share my thoughts is theraputic for me. I'm stressing over the test itself.

Keep us posted.

 

[djacq]

Tom,

I have watched your recent posts with great interest although so sorry you are going through this ordeal.

Yes, I am testing at home thankfully as it is the week end. Also, I sure did note the Lovenox dose info in your msg!!! First thing I looked for when I got the LOvenox and its on target though wished I could have had the LOWER dose.

You and Al were a major factor in my fight re: a bridge therapy. My instinct is to wait for my INR to go to 2. I will test agin Sunday.

It looks like we both will be awaiting bx results next week. They told me it would take 5 days. How about you?

Am I right that the Lovenox kicks in immediately and lasts 12 hours?

I often wonder if having an ARV wasn't enough and ask why me but then I guess why not me.

We see it over and over again, the strength of this group that permeates to everyone and it amazes me to see members getting through such trials and tribulations with such poise, bravery and good spirits.

You are in my thoughts and have been since I heard about your Colonoscopy.

Nancy, you always cheer me and thank you for the positive thoughts.
Donna

 

[Ross]

Yeap 12 hours per dose.

 

[Nan]

Donna, GOOD FOR YOU! So glad that you knew enough not to stop the coumadin with out bridging it. This is really scary.

I wish you the best with the biopsy. The good thing is that you are investigating a possible problem early on.

And I agree with Tom, please thank your son for me and all of us. Very hard to be over there.

Sounds like you have gots lots of good advice about how to proceed.

Take care.

 

[Georgia]

Donna, good luck with the biopsy. The thought gives me the willies although I know it's not painful. Nancy's right - the odds are overwhelmingly in your favor. I'm a BC survivor (15 years now) so I know the angst you're going through. You'll be in my prayers.

 

[geebee]

Donna,

I really don't have anything to add except I will be praying for you. I am going through some tough times right now but nothing like the scary times you must be experiencing.

Hugs coming your way. Let us know how things go. BTW - I am a night owl so, if you find yourself not sleeping, send me a message and we can talk.

Take care.

 

[warrenr]

Biopsy and anticoagulation

Biopsy and anticoagulation

DJACQ,

This may help you in the future if you require another biopsy. I will research the standard protocol for your procedure. For now, this may be helpfull. From my current research it does not seem like there have been any major bleeding problems when anticoagulated patients have had needle biopsy. See the below link:
http://www.ajronline.org/cgi/content/abstract/174/1/245

 

[djacq]

Warren,

How did you find that site re Sterotactic Needle Bx/Coumadin? I looked for info without much success. Thank you.

I truly believe that I am higher risk playing Russian Roulette right now with Lovenox etc than I would having the procedure with Coumadin onboard. (INR yesterday 3.7 and dropped to 1.9 today!)

It is a great service you are doing. I think all of use in this group on Coumadin are at the mercy of the medical field. We need to be armed with information to protect our lives.

This was the only site I was able to get info on the Lovenox Bridge that made any sense.

Gina,

Thank you, that was very nice of you and hope things get better for you.


It is a good day, My son just e mailed me pictures from Iraq. He looks good. One was a picture of 150 new Iraqi Army members watching them land. . Maybe I am paranoid but worry how many in that group are suicide bombers.
I can momentarly believe he is ok and safe. He is working many hours. They are flying all over Iraq and they are dropping candy to the children when they can. Some places in Iraq welcome them and some don't.

He reports "Mr. Mortar" visits his quarters daily. In fact, they call the camp "Mortaritaville"!

 

[warrenr]

DJACQ,

Through my research I am finding that even though doctor's fear bleeding complications with procedures like yours, colonoscopy's, etc. that they usually do not check INR just prior to procedure. I find it to be interesting that they are so worried about the bleeding yet they don't check INR.

I would be interested to know if they check your INR just prior to biopsy
Let me know please.

I do hope everything works out for you.

Warren R

 

[warrenr]

Forgot to ask. Is this a fairly common procedure for women? If so, I will ad it to my book.

 

[catwoman]

Warren:

I don't think it's a fairly common procedure.

I've been plagued with fibrocystic disease since about age 18, when I started having mammograms. At 34, I had a while I was in the OR for a hysterectomy. Cyst was benign.
About 10-12 years ago I required a needle biopsy/aspiration due to a golfball-size lump that literally popped up in about 48 hours' time. Doctor @ breast center injected air into cyst to "kill" it.
During my physical this week, my PCP became a little concerned about the same area. I reminded him that it's where I've always had problems. However, I'll go for an annual mammogram ASAP and take it from there.

Few of my friends have had to have needle or other biopsies.

 

[tommy]

It looks like we both will be awaiting bx results next week. They told me it would take 5 days. How about you?

Donna, ya think that I would have asked that question.

I find it to be interesting that they are so worried about the bleeding yet they don't check INR.

Warren, great point! Before my wide area excision, the surgeon ordered "stat" test at the hospital. It was 1.7 that morning at home. After waiting an hour, we went into OR without the hospital lab results. Prior to last colonoscoopy, the surgeon didn't order an INR, and I didn't do one at home either. This time I'll test at home. Interesting that I started the Lovenox bridge this time at 1.6 when for the excision I was 1.7.

Marsha, best wishes for your test as well. Better to be safe than sorry with this stuff. Hope it's a big "nothing".

 

[Marty]

Breast Biopsy

Breast Biopsy

Warren, by all means address this problem in your book.It is a very common procedure. In my Kaiser clinic the interventional radiologists do on average three of these biopsies every day.Nowadays the majority of patients are biopsied by the 11 gauge vacuum assist probe, the 14 gauge automated biopsy gun or the stereo mammotome rather than with a cutting incision..Its easy to hit a blood vessel. You found the definitive article that compares coagulated vs. anticoagulated patients( Melotti and Berg). I have seen some big hematomas.None that I know of in a patient on warfarin. They are very uncomfortable for the patient and look scary. However all have resolved treated with compression and ice. I have to believe warfarin would aggravate the bleeding. My advice would be. Don't stop warfarin but take the INR down prior to the biopsy 2.0 to 2.5.

 

[tommy]

Donna,

How did it go?

 

[djacq]

Procedure completed with results due Thurs or Fri.

I went in armed with the article about Core Needle Bx and Coumadin recommendations but never had the opportunity to give it to them. No one asked if I pre medicated or what my INR was or that I had a Lovenox Bridge.

I went into it with an INR of 1.2 and no Lovenox on board.

I did tell them at some point. The bleeding was minimal and they used a pressure dressing with ice and so far so good. It just hurts like *&^% tonight now that the local has worn off.

There were two teams involved in the procedure. One from the company that provided the machines etc and the local team including all who will be doing the procedure in the future. You see, I was one of the first to have this done at this local hospital today. There was quite a crowd.

Marty, this was the head of radiology that did it today. He had done them before at Kaiser in Calif and he was instrumental in getting the new equipment they used today.

They told me no coumadin or Lovenox today but I told them I would be taking it tonight.

The staff there was very surprised and interested in my self testing and asked where I got my testing equipment (QAS). This is one of the times I don't know how I could have done this without it.

I wonder what happens if you are on Lovenox and your INR ,like mine, would have been 3.7 when I started Lovenox if I did not pre test before going on the bridge and waiting for it to drop to 2.0 before starting it.

Tom, where is your INR now? Will you test in the morning? I hope your tests goes well with positive results. I will be thinking of you tomorrow.

Let us know,

Donna

 

[tommy]

Donna,

It's good to hear form you. So in addtion to being a pin cushion, your a guinea pig? Best wishes for the test results.

I have not taken my INR since Friday (1.7), but will take it in the morning before my procedure. I'm expecting it to be close to 1.0. My last Lovenox shot will be in a few minutes.

 

[Marty]

Donna, I'm happy your biopsy went well and that you did not get a hematoma. You did the right thing in looking out for yourself. All patients need to do this particularly those of us on Coumadin.I am always a little bit surprised when I run into an experienced doctor and find out they know nothing, have never heard of ,self monitoring and self dosing for patients on anticoagulation. Its happened to me twice now in the last year. Please refer the radiologist who did your biopsy to the paper Warren referenced by Michelle Melotti and Wendy Berg entitled Core Needle Biopsy in Patients Undergoing Anticoagulation Threrapy.Its in AJR 2000: 174: 245-249.I'm hoping also you get a "benign" report from the pathologist.