Hip pain needle procedure/bridge to Lovenox?

[Maryka]

I have been having tremendous pain in my right hip and Orthopedic doctor urged me to have a shot of Cortisone in the hip. (I am grateful I do not require hip replacement!)

I have never bridged before and cannot find any info in searching the forum except for dental bridging. (I had an emergency dental extraction that went just fine with no bridging, btw.)

Ross, I think this is your area of expertise. What to do???

 

[Ross]

There should be no reason to come off of Coumadin for a Cortisone injection. If that's what they want you to do, get another doctor. I realize that there is a risk of bleeding, but Lovenox would cause a far worse bleed event then Coumadin would. If you must, Stop 3 days before and then resume your Coumadin as soon as it's established that there is no bleeding. Sure it's a risk, but it's a small one going without Lovenox.

Be aware that your INR may increase moderately, therefor check INR 3 days after injection.

1 potential interaction was found for the drugs you selected.
You searched for interactions between the following drugs :

Cortisone
Coumadin Tablets

WARFARIN SODIUM (in Coumadin Tablets) may interact with CORTISONE ACETATE (in Cortisone)

Warfarin is generally used to prevent your blood from "coagulating" or forming blood clots. Although the cause of this potential interaction is not clearly understood, cortisone may alter the anticoagulant effect of warfarin. Based on information from one study and two case reports, cortisone may increase the anticoagulant effect of warfarin in some people and decrease its anticoagulant effect in others. This unpredictable outcome appears to be related to the individual and may also be influenced by when doses of cortisone and warfarin are taken. If these drugs are used at the same time, your doctor may want to monitor you closely when therapy with cortisone is either started or stopped. Blood tests can be used to make sure that you are getting the right amount of warfarin. If you are experiencing problems, it may be necessary to adjust the dose of warfarin.You may want to ask your healthcare provider about this potential interaction if you think you are having problems.

This interaction is poorly documented and is considered moderate in severity.

Last Updated:June 2007

 

[Maryka]

Thanks, Ross! I will contact my Johns Hopkins surgeon's office and some other, more "big time" doctors in my area for opinions. I was NOT able to talk to my own cardiologist about this yesterday, but I am also supposed to discuss this with her today. (My hip pain is excruciating, so it is not something I can just forget about, but I really want to be as safe as possible!)

 

[Ross]

Thanks, Ross! I will contact my Johns Hopkins surgeon's office and some other, more "big time" doctors in my area for opinions. I was NOT able to talk to my own cardiologist about this yesterday, but I am also supposed to discuss this with her today. (My hip pain is excruciating, so it is not something I can just forget about, but I really want to be as safe as possible!)

Dumb question but have you had it x-rayed? Yours sounds like mine just before I had it replaced and the femoral head was necrossed. It was shooting a debilitating pain from my groin straight down to my knee. I got to the point that I could not walk on it.

Reading around, many places want you to stop Coumadin because there MAY be a risk of bleeding in the joint. The question is, is the risk of clotting greater then the risk of bleeding? In my own experiences, there was no bleeding, so my lay opinion is, you should not stop the Coumadin. Certainly talk it over with your Cardio and get his/her assessment.

 

[catwoman]

Maryka:
How long have you had the pain? I'll second Ross' question about whether you've had it X-rayed.
Hope you get some relief with the cortisone shot. I've had steroid shots for bronchitis, and yes, they did increase my INR. Steroids -- which cortisone is -- usually do increase the INR.

 

[bvdr]

I've had injections into several joints without coming off of warfarin. Cortisone does tend to increase my INR for several days but not to a great extent. What is your diagnosis?

If you have steroids injected into your spine then it is a whole different scenario and you most definitely have to come off warfarin.

 

[Maryka]

Lots of decisions were made today!

First, yes, the orthopedic surgeon (part of a big orthopedic practice in my county) did all of the appropriate xrays. First they checked my lower back, which should be hurting like crazy, but isn't. (Ten years ago I had a solid year of excruciating lower back pain that stopped after I started some back exercises and after an American Indian "natural healer" friend snuck up behind me and gave me a giant hug--her hugs were her healing procedure. My back was healed and I am not arguing with the healing, which was easy and totally "for free"!)

Anyway, my healer friend has passed away from Lupus (none of her friends could heal her, sadly!).

Back to the Orthopedic surgeon: The xray of the hips showed no abnormalities except dozens of tiny cysts in the socket. There is no reason for replacement or anything, but the big shot in the hip will, most likely, heal it.

I talked with Dr. Duke Cameron's physician's assistant who never minces her words. She did not think I needed to get off the coumadin, but offered up a plan involving Lovenox if they insisted. Because I am in great pain and need to move ahead with my job search (which does not go well with me hobbling into interviews with a cane, moaning and grimmacing). I decided to compromise with the hospital doing the procedure by going off coumadin/warfarin, but picking up with Lovenox for the last couple of days before the BIG SHOT into my hip. This is pretty daring stuff for me because I am going to have to give myself injections twice a day. I am totally squeemish about giving myself or others injections, whick is why I dropped out of Nurse's Training 40 years ago, months before graduation.

The local hospitals in my area (Montgomery County, MD) seem to hold to this "no Coumadin" rule. If there had been time, I could have probably lined up going to Baltimore again to Johns Hopkins. Yeah, I am scared, but feel I am doing the best I can muster right now.

 

[bvdr]

I'm glad you have a plan and that soon you are to have relief. Reading your last post about tiny cysts in the socket jogged something in my memory about development of "cystic" bone as part of the deterioration of the joint in the arthritic process. I'll have to do some research but if that isn't the case I'll get back to you.

It is the experience of many of us who have been on Lovenox that bleeding and bruising during that time is more than when on warfarin. Do be kind to yourself during that time and avoid rough activities. And,...good luck with your job hunt!

 

[bvdr]

Maryka, you might find this article about osteoarthritis interesting. http://osteoarthritis.about.com/od/osteoarthritisdiagnosis/a/x-ray.htm

 

[Maryka]

Thanks for the good words and information on those cysts! I have loose connective tissue, especially below my waist, so I am aware that I will probably face joint after joint going bad. It is the severe pain that I object to, ha ha! So, as you suggested, I hope to take it easy this weekend and learn to give myself those Lovenox shots. Now that I am using my cane to even wander 5 feet within my house, my pain level is just a bit lower.

I had a surprise job interview yesterday (my resume is everywhere right now), but warned them I would be coming in with a cane. (I had not warned some interviewers last week and I think they were a bit shocked.) I told them that I am supposed to be mobile and pain-free after my procedure Tuesday, but only time will tell. (You know, they are not supposed to practice prejudice against your age or your disabilities these days but try proving that you were discriminated against!). Right now I am preparing to go to the cardiologist to have my current INR reading and my training on how to inject Lovenox. Oh, joys!

 

[Ross]

I know what you mean about the pain and prospective employers.

I know one day, I got out of bed and just put my weight on it and collapsed in total pain. It even hurt to hobble to the closet for crutches.

Here ya go, get a jump on the Lovenox injecting techique:

http://www.lovenox.com/consumer/download.aspx?file=How-To-Inject-Guide_p.pdf&type=download

 

[Maryka]

I had my training from the (Silver Spring) cardiologist's nurse this morning and picked up the Lovenox at the drug store. Hoo Boy! You were not kidding that it is expensive! It cost so much that the credit card company telephoned me immediately asking if my card had been stolen and was being used by someone commiting fraud! Yow! (BTW, my PT score was 2.0 this morning after two days off my Warfarin.)

Thanks for lthe ink and the injection tips! I start first thing tomorrow morning. The moment of truth! I just have to remember I want to get over the hip pain...

As for the job hunt: I may go onto Social Security, which may well lead to my filing for bankruptcy. I am trying hard to think this will all work out in the end!

 

[ALCapshaw2]

Maryka,

Apparently there is NO Single Standard for Bridging.

I asked 3 different Surgeons about their Bridging practices and got 3 different answers.

1 - Stop Coumadin 2-5 days before the procedure.
Start Lovenox 1 day (sometimes 2 days) later
Stop Lovenox 24 hours (sometimes only 12 hours) Before the Procedure
Resume Lovenox AND Coumadin that night (several hours After the Procedure).
(I have come to believe it is wise to Wait 24-48 hours before resuming Lovenox, especially if there is a risk of bleeding.
(It is usually OK to Resume Coumadin several hours after the procedure because it takes a few days to become fully effective)

2 - Use Lovenox BEFORE the procedure as above
Do NOT use Lovenox AFTER, just resume Coumadin that night

3 - Do Not Use Lovenox at all, Just stop Coumadin X days before and resume After the Procedure.
This would seem most appropriate for High Bleeding Risk Procedures.

After reading many posts / experiences and thinking about those alternatives, I can see reasons for each approach depending on the situation. After Ross' experience with Total Dental Extractions and Lovenox, I have a better feel for the Bleeding Risk from Lovenox and feel more comfortable with the idea of holding off on Lovenox after the Procedure until the Bleeding Risk is assessed to be minimal.

Best Wishes for your Procedure!

'AL Capshaw'
\

 

[Ross]

I had my training from the (Silver Spring) cardiologist's nurse this morning and picked up the Lovenox at the drug store. Hoo Boy! You were not kidding that it is expensive! It cost so much that the credit card company telephoned me immediately asking if my card had been stolen and was being used by someone commiting fraud! Yow! (BTW, my PT score was 2.0 this morning after two days off my Warfarin.)

Thanks for lthe ink and the injection tips! I start first thing tomorrow morning. The moment of truth! I just have to remember I want to get over the hip pain...

As for the job hunt: I may go onto Social Security, which may well lead to my filing for bankruptcy. I am trying hard to think this will all work out in the end!

If you have to go the SSDI route, get a lawyer from the get go and get a letter from your Ortho stating that with absolute medical certainty it is affecting a major weight bearing joint. That should speed the whole process up for you. Wished I'd of known it long before I found out. Took me two years to get approved, but once I had the documentation in hand, all it took was a phone call from the attorney.

 

[Maryka]

Well, I turned 62 in January, so I qualify for regular Social Security. Is it possible to go on SSDI if you are qualified to go on regular Social Security? That is a good tip about the major weight bearing joint, though! It makes total sense!

I survived giving myself my first injection this morning. I have 5 days of injections ahead of me (three days before the hip shot and two days after the day of the shot while getting back on warfarin again), so I imagine I will have a lot of bruising before this is all done. (Not that I was thinking of wearing a bikini or anything.)
My brother (my only sibling) went on SSDI when he was in his early 50's due to a back problem that caused him to be paralyzed from the waist down. It was horrible for his kids (all in Florida--a long way from where I live) to get him put in a medical facility. Finally they got an attorney who fixed the situation! My brother has lived in a nursing home ever since then as a sort of "ward of the state". But at least he is not on the street and gets the skilled nursing care he needs. When my hip is hurting, I can see the up side of my brother's life! (He watches TV 24X7 and gets "three squares" plus snacks, etc.)