Heparin instead of Lovenox

[twinmaker]

I'm not exactlyl sure where to put this thread, so I trust Ross will guide it to where it should be. I went to the Gastroenterologist last week for acid reflux. I had a barium swallow last Friday. It showed a moderate stricture in the lower esophagus right above the stomach. The radiologist said it was a 40% narrowing. Anyway, I'm sure the next step will be an upper endoscopy. I saw my cardiologist today for my 6 month checkup (everything is perfect with my heart...YEH) and he wants me off the coumadin for the endoscopy because they will probably take some biopsies and also flatten the stricture with balloons. I told him that I would not do the Lovenox route because of the pain in my abdomen and the subsequent hematoma that I had for well over a year the last time. He said there wouldn't be a problem doing the Heparin drip. My question is: It's been a while since I did a Heparin drip. Do the insurance companies frown on going this route? Also, does anyone know where my INR (mechanical mitral valve) should be for this procedure? Sorry to ramble on. I'm also scared about having Barrett's esophagus. Anyone have any experience with it? All this reflux stuff has put a damper on my good cardio checkup today. I don't have to go back in there for a year. Any help with any of this would be appreciated. LINDA

 

[bvdr]

HI LINDA. I'm sorry you are having GI stuff going on that has put a damper on your good cardiac check-up. I would expect you would want your INR pretty close to 1.0 if you are having esophageal biopsies done. I know that Barrett's esophagus is associated with longtime GERD and carries an increased cancer risk because the lining of the esophagus has changed but I don't have any personal experience with it. Have you already been diagnosed with this? I'd get pre-approval for the Heparin drip just in case. How big a hematoma did you get with the Lovenox?

 

[twinmaker]

Betty, I haven't been diagnosed with the Barrett's. I know I'm jumping the gun, but when the radiologist saw the stricture, I asked if it was a tumor and he replied no, but did mention that the gastroenterologist would probably do an endoscopy to flatten the stricture and he also mentioned the possibility of Barrett's as did the Gastro. when he first saw me. I'm a worrier, so you can imagine what is going through my head. As far as the hematoma, it was huge. And right after using the Lovenox the last time, I had the worst pain in my abdomen. I couldn't sit or walk because of the pain. This went on for several weeks, and I promised myself...never again. I had some pretty bad break-through bleeding on Lovenox another time when I had my breast lumpectomy. That was done inpatient with Heparin, but I was sent home with Lovenox. Two days after starting it, I had excessive bleeding from the site of the lumpectomy and hadn't had any bleeding from it for the whole week before I started the Lovenox. I will make sure to get pre-approval from the insurance company for the Heparin. LINDA

 

[ALCapshaw2]

Hello Linda,

I have some experience with your upcoming procedure (except my GI Doc used 'tapered rubber tubes - filled with Mercury I think - eek!)

"Flaten" is euphemistic for STRETCH, which can result in tears (pronounced 'tares') and that is likely to have some (hopefully minor) bleeding.

Bottom Line: He will probably want your INR to be 1.0 for the procedure. Same story 'even if' he only were to take a biopsy, at least that is what MY GI Doc would say (I've already heard it).

I've not had the post-Lovenox difficulties you describe, but I probably have er-ah, 'more insulation'. Did you pinch your belly to 'bunch it up' at the injection site?

Getting pre-approval from your insurance company for the Hospital stay and Heparin Drip is probably wise.

'AL Capshaw'

 

[twinmaker]

Thanks for the info Al. Believe me, I have enough insulation in my tummy. I've always bunched it up when I did my injections. The pain was just so bad that I literally couldn't sit and had difficulty walking after using it the last time. I can still remember the pain and it's been almost three years ago. Did you have bleeding when your stricture was stretched? How bad was the procedure? I'm not looking forward to it, but I know that it needs to be done. LINDA

 

[ALCapshaw2]

Thanks for the info Al. Believe me, I have enough insulation in my tummy. I've always bunched it up when I did my injections. The pain was just so bad that I literally couldn't sit and had difficulty walking after using it the last time. I can still remember the pain and it's been almost three years ago. Did you have bleeding when your stricture was stretched? How bad was the procedure? I'm not looking forward to it, but I know that it needs to be done. LINDA

I'm sorry you have had such a time with Lovenox Linda.

It sounds like you need for your GI Doc and your Cardiologist to consult on the best way to proceed, and to keep YOU in the loop.

Fortunately, my "dilations" were done BEFORE I had AVR so there were no issues with anti-coagulation. I remember seeing ONE picture which showed some 'red' at the stricture but no active bleeding (no puddles, no flowing blood).

I DID Bridge with Lovenox for a combined Colonoscopy and Upper Endoscopy because my GI Doc wanted to be able to remove any polyups he might find (NONE) and take a Biopsy (he Did NOT). Oh Well, at least the tests were negative and I probably won't need to repeat until 5 years have passed.

Did your GI Doc say why you have GERD and subsequent stricture(s)? Are you taking any of the usual medications (Prilosec, Nexium, etc.?)

'AL Capshaw'

 

[ALCapshaw2]

One more question about your Lovenox injections.

Did you inject rapidly or slowly?

I went S L O W to try and let it diffuse some before the full dose was administered.

'AL'

 

[twinmaker]

Al, thanks for all your input and concern. I suspected I had GERD because I was having that sour tasting acid literally shoot up my throat into my mouth at night while I was sleeping. I didn't have it that often. At times, I would go for several months and not experience it. This started about 8 years ago. (I know, I know...should have done something before now). But I never ever felt the classic heart burn symptoms, like burning in the chest, etc. I had pneumonia back in March and I suspected then that it might be due to aspirating some of this fluid as I had had some episodes with the reflux of fluid and aspirating it right before the pneumonia. I have done that several times over the years. I wake up choking and coughing. When I saw the gastro. doc last week, he immediately put me on Nexium. I'm taking 40mg. a day. I'm trying to also make the necessary lifestyle changes. I'm going shopping today to get a wedge to sleep on. I'm also eating smaller meals and have stopped (cold turkey) drinking soft drinks, and not eating within 3 hours of going to bed. I'm also going to try to lose some weight. My cardio told me yesterday that Nexium may affect my INR but not that much. I will monitor that myself here at home. The radiologist said the stricture is from the stomach acid burning the esophagus and then when it heals it leaves scar tissue. The process is then repeated and repeated leaving a stricutre or narrowing. As far as injecting the Lovenox, I've always done that slowly. I rotated my sites. I didn't remove the air bubble before injecting. I don't know what else I could have done. I guess this is the frustrating thing about being on Coumadin... having to have a procedure done and not having a good history with Lovenox. LINDA

 

[ALCapshaw2]

It sounds like you did all the right things with your Lovenox and still had problems... Sorry about that. Time for Plan B as you are doing.

Yep, eliminating acid drinks is a Great Help in reducing Reflux. Also cut out (or reduce) intake of Chocolate and Peppermint and clothes that are tight around the waist. (Chocolate is MY weakness ;-)

I raised the head of my bed about 6 inches using Bricks under the legs of bed.

I've been on Prilosec since before Coumadin / Warfarin and have little trouble maintaining a reasonably stable INR.

Hope all goes well with your procedure and that there is no indication of Barrett's esophagus. Once you get your reflux under control, there is a good chance your stricture will heal on it's own (after getting stretched).

Then, with constant vigilence and regular checkups, hopefully you won't have any more 'issues' with reflux.

Best of Luck,

'AL Capshaw'

 

[Marty]

Bridge or "hold"

Bridge or "hold"

I will be the devil's advocate here. As i've posted previously most of the cardiologists here are comfortable with a 4 day hold and check the INR the day of the procedure. My cardiologist says he has never had a patient who got into trouble with this. Our GI's will always do these holds if it is OK with the cardiolgist. I personally would hold for this procedure and not do the bridge either with Lovenox or heparin.

 

[twinmaker]

Marty, thanks for playing devil's advocate. I do that quite a lot myself when I'm trying to make a decision. I've tried doing holds in the past with the consent of my cardiologist and I'm never where they want me to be when the procedure is to be performed. Tried this twice and both times I had to have fresh frozen plasma and had allergic reactions both times. The first time was mild and the second one wasn't so mild. With my track record, if I did another hold, I'm afraid I'd have a stroke. LINDA

 

[Kathleen]

Linda I don't want to be a wet towel on the Heparin/Lovenox decision but the last time I came home from the hospital with heparin shots I got a huge hematoma from the heparin and spent months and months in sweat pants. I have never used Lovenox and don't know if it would be the same for me. I have also had a bleed out from a GI issue and we only held overnight for the upper GI and then a couple of weeks later we held for two days for the removal of the mass in my stomach. I take Prevacid daily and it has never made a difference in my INR but has been wonderful on the GERD. Hope all goes well for you.
Kathleen

 

[PeggyM]

I hate the lovenox too and have been doing it twice a day now since before the angiogram, which was 3 weeks ago! My INR just isn't coming up. I told them yesterday I'm not doing it anymore so we're raising the coumadin.

My first experience with lovenox years ago was a nightmare and like you I still remember it. It's nurses in a rush injecting you fast that caused me so much anguish. Next time in the hospital, I am not going to let them do it and will do it myself! Slow and easy is the only way. I dreaded doing it again twinmaker, but have been forcing myself. The stomach is one mass of black and blue.

There is just something about causing yourself pain that isn't right!

 

[twinmaker]

I've also had a hematoma from Heparin when my first pacemaker was implanted, but I can honestly say that the pain from that was no where near the pain I felt the last time I used Lovenox. I wonder if my body is reacting to the Lovenox in a certain way that doesn't affect most people??? Like an allergic reaction, even though I know the symptoms would probably be different if it was a true allergy. Oh well, we'll see what happens. I really appreciate everyone's imput. I did speak with the gastroenterologist's nurse yesterday and she said he was on vacation until the first week in September and hadn't seen my report from the barium swallow or the note from my cardiologist. I am anxious to see what he thinks about all of this. LINDA

 

[alicia]

Hey Linda, I can retate. I've had barretts esphogus for 10 years now and I have endos every 6 months and my gastro dr never takes me off Coumadin for the procedures. I had a horror of taking Lovenox twice daily for 10 days and I vowed to never go thru that torture ever gain! When I need Lovenox for bridging, I opt to go into the hospital for a Heparin drip. Its very boring, but mentally and physically could'nt go thru that again. I have GERD too and am on all sorts of meds. Between all my cardiac and gastric problems, Im on 13 different medicines daily. Its a chore but it beats the alternative. Good luck to you. Where is Denver,NC Im in Greenville,NC

Alicia

 

[bvdr]

I've never gone in the hospital for a heparin drip (except for immediately before MVR) but always opted for the Lovenox instead. I do find the Lovenox painful though and usually end up with "eggplant belly" from the injections. This bruising lasts many months. In fact, a few years ago when I was in the hospital with transient ischemic colitis I was even given Lovenox there rather than heparin.

I am more leery of Lovenox though than either heparin or warfarin. The last time I was on it I woke up during the night with the front of nightgown all wet. When I turned on the light my heart jumped a beat. I had dinner plate size bright red blood spots that had oozed out from the last 3 or 4 injection sites. Remember the Godfather movie? The blood was everywhere! I have an above normal blood supply so I really wasn't worried. I did however wait several extra hours before giving myself the next (and last) ordered dose.

I know it isn't an easy choice though. It is a big downside of the blessing of warfarin.

 

[twinmaker]

Thanks for your responses Alicia and Betty. Betty, I had the same thing happen as you with waking up to being covered in blood where my breast lumpectomy was done. I had been in the hospital for several days on heparin and everything was fine, then was released on Lovenox and the surgical site had blood seeping from it. Alicia, thanks for your imput on Barrett's. It sounds like you are managing well since you've had it for 10 years. I know it must be hard to go for endos that often, but it beats the alternative. You can tell I've been doing a lot of research on it! I go back to the gastroenterologist on Wednesday. When he came back from vacation and saw the barium results, his nurse called and said he wanted to see me this week instead of my scheduled appointment which was the middle of October. He wants to discuss the endo and the coumadin issue. As far as where Denver NC is...Denver is a small town located on Lake Norman. We are about 20 miles or so from Charlotte. Where is Greenville, NC located? We've only lived in NC for 18 months so I'm not real familiar with all the cities yet. LINDA