Here' good queston for Al

[Nancy]

Hi Al-

Is there a difference in post surgical bleeding with the use of in-house (hospital) Heparin and out patient Lovenox?

They're having a very hard time stopping post surgical bleeding after Joe's surgery on Friday and there have been some comments that Lovenox doesn't give the control that IV Heparin does.

He has a major abdominal bleed right now, after gallbladder and liver biopsy surgery.

What's your experience?

 

[Guest]

This is an extremely difficult question to answer. The type of heparin they give IV in the hospital is called unfractionated heparin (UH). The dose is very uncertain for a great number of reasons. But once the correct dose (# of units per hour) is determined, it is fairly easy to manage. It can usually be controlled by just turning off the IV. If that doesn't work, and bleeding occurs, there is a well know formula for using protamine to neutralize the heparin.

It is much easier to find the dose of low-molecular-weight heparin (LMWH) because the part of the molecule which causes trouble in UH has been removed. However, in a few people, this is not really the correct dose and they will start to bleed. The longer time that LMWH will work in the body is now turned to a disadvantage because protamine does not work as well at neutralizing LMWH.

This makes it a difficult call. If the person is going to be hospitalized (which also means that they are likely to be less stable), UH is probably a slightly better choice because of the ease of neutralizing it. BUT and this is a big one, patients do not like to be getting stuck in the vein every six hours to monitor the UH. They get magnificent bruises and complain to everyone who comes near them. This makes doctors tend to shift in favor of the LMWH.

UH is dirt cheap but requires expensive monitoring. LMWH is expensive but ordinarily requires no monitoring. (We do not even have a way to do it in Pueblo.)

It comes down to the fact that there is no right answer. It is debated endlessly. There are no sales reps pushing UH and there are platoons of them pushing LMWH. This helps keep the debate alive.

I hope Joe is doing better today.

 

[KIRSONRON]

I'm glad this topic came up. I had a screening colonoscopy in January of 2001. We all decided to perform the procedure while I remained on Coumadin - rolling the dice that nothing that needed surgical removal would be found. Unfortunately, the gastroenterologist did find a pre-cancerous polyp that needed removal. I was sent home and told to stop the Coumadin and return in 3 days to have my INR checked to see if I should be admitted and placed on heperin prior to the surgery. When I returned, my INR had dropped to 1.4 and the polyp was removed immediately. Post surgery, I was admitted to the hospital and placed on a Heperin IV to control my INR until the Coumadin took over again. I am now facing another colonoscopy because of the last biopsy. I'm curious about the LMWH. I know it's a self injectable drug, taken 2 times per day with the dose based on body weight. Does anyone know how effective this is? I do home INR testing now, and wonder if using the test unit will adequately monitor my body while on the LMWH. Any thoughts or experiences with this?

Thanks,

Ron

 

[Guest]

The LMWH bridge therapy is extremely effective and recommended for people who have mechanical valves and need to go off warfarin.

Whether or not you can use the home testing devices when you are using LMWH is debatable. Roche says that they have no data and therefore cannot recommend using CoaguChek. But, I have tested a few people using both CoaguChek and the hospital lab and have found no difference.

A possible pitfall, your insurance may not want to cover it. You can usually appeal and get this overturned but it is not something you want to wait to do until you are double-parked and your spouse is waiting in the car with a screaming kid. Start by calling the customer service number for your insurance well in advance.

I have given a talk on this subject to a state pharmacist's convention, so I am pretty familiar with it.

 

[KIRSONRON]

I use the ProTime unit now. Your insurance comment puzzles me. Are you referring to the LMWH that may not be covered? If so, I will definetely check that out after I discuss its use with my cardiologist next month. If he concurs that it can be used as an alternative to coming off Coumadin, then I will contact the insurance company to see if its covered. If he does not concur, I will have the next colonoscopy on the Coumadin and roll the dice that nothing will be found that requires removal. That's my gastroenterologist's suggestion. Take LMWH or stay on the Coumadin - he said that the odds are low that something else will be found so soon.

Thanks,

Ron

 

[Guest]

Yes, it was LMWH that may not be covered. Many prescription plans do not cover injections except insulin. LMWH can cost about $100.00 per day. You probably need 5 or 6 days of it.

 

[KIRSONRON]

Thanks for the info. I'm going to go onto the ProTime thread and ask the question regarding the use of their machine for measuring the INR when the anticoagulant is LMWH.

Ron

 

[Gisele]

Cost of Lovenox

Cost of Lovenox

I keep a handy supply of Lovenox on hand (INR's are never stable). I was going to my local drugstore and my BCBS was covering 80%, but even at that it was still costing me close to $50.00 for approx. 10 syringes. I then decided if I was going to be a frequent user of Lovenox (after spending close to $500.00 already) that I would attempt to see if mail order with my BCBS would cover this. I made one phone call and the clerk said it would be covered. Wanting to make sure, I called again, and this time was told it was not a covered service. I decided to try mailing in a script for 20 syringes (60 mg ea) for a ten dollar co-payment. To my surprise they did arrive in the mail. Now when my INR drops below range I have it on hand for those times when my MD orders me back on it. From having so many doses over the past few months, I have begun to see what appears to be a permanent discoloration around my belly button. Kinda like a faded bruise. I guess that is the price to be paid, but it doesn't show unless you really get up close.
Even though Lovenox is a scarey thing for me after my bleed in my hip from the Lovenox it sure beats going into the hospital and getting tied to a Heparin IV like years ago.
Good luck with your insurance.........Gisele

 

[LUVMyBirman]

Ni Nancy,

Sorry to hear Joe is having a hard time of it. Here is my 'two cents'.

I appear to be one of those individuals that are extremely sensitive to the introduction of Coumadin/Lovenox combo and or.... Coumadin/Heparin combo after an invasive surgical proceedure.

As my levels start to come up, and when overlapping with both drugs.....I start to bleed. Once seriously with tamponade. The other not as serious, but was still an issue with my wisdom teeth extraction's.

I am more afraid of a post op bleed, than going though an actual procedure. My doctors have not been able to figure this out.

Any information would be greatly appreciated.
Thank you.

 

[Greg T]

Another good question for Al (men only please)

Another good question for Al (men only please)

Hi Al:

I read your response to this question on your web page, but I was wondering if any one here as had any experiences or if you have heard of any further info about:

Coumadin & Viagra

I amd not a former senator or a baseball player, but I have had an AVR recently and am looking to resume my sex life (so is my wife!) so any comments (constructive ones please) would be helpful.

Thanks,Greg T

 

[Guest]

I have tried to cover this on my web page too. Please look at
http://www.warfarinfo.com/sexual-activity.htm

I also have a hunch that you could start a new thread and get lots of first-hand information.

 

[Zipper]

Woman, too...

Woman, too...

Sorry Greg..I am not male..but we are all sexual beings, and I read Al's page on this and thought it was so well put. The stress on the "emotional love", I found to be a strong indicator that everything will be fine if everyone has their 'mind' in the right place! Quite frankly...we all, being mature, know the 'mind' rules!! I think Al is right...start a thread on this...I bet you'll get lots of input. It's a vital subject that everyone can benefit from sharing!

Zipper

 

[cookie]

Hi Nancy!
I had asked my Doc about the difference between Lovenox and Heparin and he said that they have no control over the Lovenox - it just has to wear off. Whereas Heparin, they can control. Something about Lovenox being intra-muscular and Heparin being in the bloodstream. He doesn't like using Lovenox. I don't know whether Docs have a preference for one or the other but, I believe I would much prefer the Heparin.

 

[Nancy]

I asked one of my husband's rounding cardiologists (not his regular one, but from the same group) about that very thing when my husband was last in the hospital with a post op surgical bleedout.

His statement was that they use Lovenox pretty much exclusively now, because otherwise, the patient would have to be in the hospital about 5 days before surgery to have IV Heparin, and 5 days and maybe more after, until the INR was therapeutic.

Joe has been in this situation in the past many times.

I bet your bottom dollar that insurance companies are weighing in heavily on that issue. Extra hospital days are very expensive. When you can give yourself the injection at home, it's much cheaper, even though the Lovenox is expensive.

I guess I'll never know if my husband would have done better with the IV Heparin. I felt the IV Heparin would have been much more precise, but there was absolutely no choice.

I also wondered if the Lovenox lingered in his system, even though his INR was checked prior to surgery.

 

[Guest]

Cookie, Your doctor's answer is out-of-date. There is now a formula published for partially reversing Lovenox.

The main differences are

Lovenox Heparin
Expensive Cheap
Usually no monitoring Expensive monitoring
Easily given at home Has to be IV for accuracy
Highly predictable Unpredictable
Partially reversible Quickly reversible

Probably 90% of doctors are using Lovenox (or Fragmin) because of the ease of use. It is not without problems, the major one is that people who are very sick can have the drug accumulate and then they tend to bleed.

 

[KIRSONRON]

I had just asked my cardiologist about this last Friday. I'm scheduled for a colonoscopy later this year as a follow-up to a polyp removal done in January of 2001. He was adament that I not use Lovenox - saying that the results are too chancy with an AVR to risk a clot with catastrophic results. So I'll take the test on Coumadin and if they find anything, do what I did last year - come off Coumadin and go on Heparin. At least thats his opinion.

 

[Guest]

I think that doing the procedure while still on warfarin is the best. I have seen patients simply removed from warfarin and have a stroke while waiting for the colonoscopy. Congratulations to your GI doc for not being afraid to do this.

The Lovenox - AVR risk was for women with pregnancies. It takes a huge leap to apply this to all women with AVRs.

 

[KIRSONRON]

My GI is really great - and not afraid to "work" on people who take Coumadin - something many doctors shy away from.

With regards to the Lovenox question, both my GI and internist deferred to the cardiologist on this. His concern is given the high degree of anticoagulation required with AVR and the inherent danger of clot formation, he would feel better that if another polyp is found, removal be done on Heparin. I've read many good things about Lovenox in this forum, but - if you are going to use a doctor, you have to rely on his judgement - or find another doctor. Last time, I hemoraged 36 hours after the polyp removal and was certainly glad I was in the hospital - on Heparin. In matters such as this, I would rather be less than "cutting edge". If time proves his fears unfounded, I'll gladly move on to the Lovenox.

 

[cookie]

ALLODWICK,
Can I quote you on that? I certainly want to keep my Doc up to date! He's a fairly young guy but maybe a bit overwhelmed with a patient overload. Not enough time to catch up on his reading? Thanks so much for clearing that up. Sometimes I think I trust my friendly pharmacist (who runs my anit-coagulation clinic) and you for more accurate info.

 

[Guest]

Yeah, I think that it is in the PDR under Lovenox. The reason that this sticks in my mind is that I can remember when I got trapped by the same question.

I don't write anything that I would not want to be quoted on. I deal every day with helping other keep up to date.

Just so I don't sound too smug, I try to keep in perspective that everything I know, I learned from someone else. There is no magic in what I do. I just have been fortunate enough to be able to concentrate on one subject.