Lovenox?

[Marty]

Because of the continuous confusion about "bridging" and the efficacy of Lovenox, I asked my surgeon what he thought about it. Here is his reply.

"Marty, Lovenox is totally inadequate. It says so in their own literature. They have sent out big yellow warnings about it. Despite all this, it goes on. A few years ago I operated on a man that had a partially clotted St. Jude valve a few months after temporary Lovenox for a colonoscopy. I was going to write an article about it......and still may do it, although someone from Israel wrote such a report. That's about all I know about that topic. Regards, Ed"

Now where does this leave us? My cardiologist does not bridge with Lovenox or unfractionated heparin in hospital drip and says he has never had a complication holding for three days.

 

[Ross]

It's my understanding that many have never had complications arise as of yet, but the key word is yet. You just know someone is going to clot, throw it, and then there's going to be hell to pay. With all the lawsuits and insurance disasters awaiting physicians everyday, I would think they'd err on the side of caution and just do it.

It boils down to the game of statistics. Lets say 98 to 2 that it doesn't happen, but to the physician that it does and facing a lawsuit, do you suppose those stats mean a thing from here on out?

 

[Marty]

It's my understanding that many have never had complications arise as of yet, but the key word is yet. You just know someone is going to clot, throw it, and then there's going to be hell to pay. With all the lawsuits and insurance disasters awaiting physicians everyday, I would think they'd err on the side of caution and just do it.

It boils down to the game of statistics. Lets say 98 to 2 that it doesn't happen, but to the physician that it does and facing a lawsuit, do you suppose those stats mean a thing from here on out?

Ross, You are so right. I think that many docs that do "bridge" do it for medicolegal protection not because of great faith in Lovenox. In medicine today a huge number of expensive procedures and tests are done to " buff up the chart" for the lawyers.

 

[Nancy]

Joe had an interesting thing happen with Heparin while last in the hospital.

He was initially admitted for splenic infarctions. He had a high flutter heart rate of 120. He was also admitted, I believe, under the Internal Medicine dept., although his cardiology group was involved, but were secondary at first.

So right away, they stopped Joe's Coumadin and put him on Heparin drip, in case there was a possibility of having to do surgery on the spleen. A couple of days went by, and cooler heads prevailed, and after a few meetings, it was decided to not operate, that he needed all the spleen he had. And the infarctions had stopped hurting.

So then he was put back on Coumadin with Heparin drip until the INR got therapeutic. And a higher level 3.5-4.0 was decided upon.

Enter a new Internal Medicine doc, who announced that she was taking over the case.

In the meantime, Joe developed a bacterial infection. So this woman made a decision that Joe either was allergic to Heparin (he's not), or that he had developed sepsis from the Heparin . She took Joe off it.

In came the cardiology group, and asked why Joe was off Heparin, since he wasn't therapeutic and had already thrown clots. At that point Joe got rid of the Internal Medicine gal, and asked the cardiologists to take over the case. They immediately put him back on Heparin.

She could have killed Joe. She had very little understanding of cardiology problems.

So, I really don't know what to make of those who think Heparins have no value. They must offer some kind of protection. At any rate, I certainly didn't want my husband to be without any anticoagulation.

Lovenox is not used on Joe because he has some kidney issues.

 

[Karlynn]

As someone who has yet to do any bridging therapy, or had a need for it, I'm finding this all very confusing. And it seems to keep getting more confusing.

The neophyte that I am with bridging, it would seem that if Lovenox or Heparin is an anticoagulant = that would equal the less chances of clotting for someone with a mechanical valve. If it leaves the system within hours - that would seem the way to go for someone who is on warfarin therapy and must stop it for a procedure.

I just don't think I would at all comfortable being totally unprotected for any length of time.

As someone who is on a fairly large dose (9's and 10's) my INR would drop rather quickly upon stopping the warfarin, but it would also be harder to get it up again after a procedure. It's that "after" that is more frightening to me. But the "before" is also a concern.

 

[Marty]

Lovenox

Lovenox

I am not sure, but I think it is just Lovenox that is so controversial. Unfractionated heparin by drip in hospital may still be OK. I have asked Dr. Lefrak to clarify this for us.Heparin has been around awhile. I used it in 1950 as an intern on the vascular service at IU. However we sure use a lot of Lovenox at my Kaiser clinic in Falls Church. Every time we pick up the very common deep venous thrombosis in the legs by sonography the patient goes right on Lovenox and stays on it till warfarin takes over. I'm just as confused about Lovenox bridging as every body else is. I'm thinking now that if I needed major surgery I'd prefer to go in the hospital and have heparin. For endoscopy I would stay anticoagulated or maybe if I was feeling lucky- hold..

 

[Karlynn]

or maybe if I was feeling lucky- hold..

Is this the Dirty Harry Method? "Are you feelin' lucky, punk."

 

[Nancy]

Marty-

Please never hold your anticoagulation. Go on Heparin drip. You've had a serious eye issue. Joe's luck ran out on Lovenox once and it almost cost him his life. I will NEVER forget it. And his luck almost ran out again when he threw the splenic infarctions. That was from a dip in his INR to 1.8 while he was having to use heavy diuetics (Zaroxolyn). It could just as easily gone to his brain or heart.

Never again. His crap shoot hasn't been a lucky one.

 

[warrenr]

links

links

Links about lovenox bridging. Marty, maybe you should have your cardio read these. Your cardio told you he had a patient that had valve thrombosis several months after temporary lovenox bridge. I am not a cardio but would doubt that lovenox had anything to do with the thrombus since it was several months after lovenox. It would be interesting to know what the patients INR levels were for the month prior to the thrombus while on coumadin.

http://www.ajhp.org/cgi/reprint/61/9/899.pdf
http://www.vapbm.org/criteria/enoxaparincriteria.pdf
http://www.clinicalconsensusreports.com/Secure/HospPharmAPPCR.htm
http://www.princetoncme.com/pdf/Heparin_PrinterFriendly_2004-84-3.pdf

 

[Ross]

Here's my Lovenox man!

 

[Karlynn]

Thanks Warren. Sounds like somebody paniced after a small, faulty, study.

 

[ALCapshaw2]

I'm still on my Lovenox Bridge following an Upper Endoscopy and Colonoscopy (with one biopsy).

Just before my procedure, I had a 'twinge' and 'cold sensation' on the right side of my face, neck, and shoulder. Fortunately, it cleared after a minute or two. An EMT who just happened to be in the lobby checked my reflexes and tried to get me to go to the ER and cancel my procedure. He suspected a TIA.

I did call the GI Doc who told me to come right up and had his nurse monitor me until the procedure time. Following the procedure, I had some 'visual effects' (who several suspected was more likely due to the Versed).

Bottom Line: I think I 'dodged a bullet' and would hate to think what might have happened if I had NOT been on Bridging Therapy. And I hope I won't have to repeat either of these procedures any time soon. There is NO WAY I would just 'roll the dice' going OFF Coumadin with some sort of Bridging!

'AL Capshaw'

 

[ALCapshaw2]

OOPS!

Make the last statement in my previous post read:

There is NO WAY I would go OFF Coumadin WITHOUT some sort of Bridging Therapy.

'AL Capshaw'

 

[ALCapshaw2]

How does Lovenox Work?

How does Lovenox Work?

Am I correct it believing that Lovenox does NOT affect INR?

If so, how DOES Lovenox work to prevent clots?
Is it an anti-coagulent?

Same question for the Heparin drip....

'AL Capshaw'

 

[Karlynn]

Correct - Lovenox does not show in the INR.

 

[Guest]

There are a whole bunch of steps in the clotting cascade. Heparin and Lovenox work on Factors II and Xa warfarin works works on the conversion of prothrombin to thrombin. Since the clotting test (prothrombin time {PT}) only measures this step in the cascade, heparin will not affect it. The partial thromboplastin time (PTT) is what measures heparin activity and it is not affected by warfarin. Lovenox does not affect the PTT so you have to do an anti Xa test to measure it. However, few hospitals have the capability to get this done within 24 hours, so it is largely meaningless.

It is interesting how many doctors think that heparin is approved for use in patients with mechanical valves when it is not. It has never been studied. The only advantage it has is that it will go away faster than Lovenox if something goes wrong.

At our anticoagulation meeting in May we had a session on bridging. One doctor said that he only bridges the highest risk cases (mitral valves) and another said that it is rare that he does not bridge. Both medical school professors.

I was a big proponent of bridging until I prepared the talk for last year's reuinion. I had a chance to talk with one doctor who had just written an article on it and I concluded whether you do or not the outcomes are just about what you would get by rolling dice.

What had not been figured out a few years ago was that Lovenox is cleared by the kidneys and if someone has kidney failure, they will not get rid of the Lovenox and bleed. Now we know how to avoid that. There is propbably more known about bridging with Lovenox than there is with heparin because there haven't been any studies about heparin and there won't be. There are ongoing studies with Lovenox. But, they will never offer "proof", only some evidence. However. it still seems not much better than crap shooting.

 

[Lisa in Katy]

It doesn't make sense to hold Coumadin and not use either Lovenox or Heparin. Seems to me that "something" would be better than "nothing". It is interesting to hear that Lovenox doesn't show in the INR. Now I understand why my INR was 1 point something after a week back on Coumadin even though I had used Lovenox bridge and was only off Coumadin for 3 days to have my wires removed. My INR bottoms out if I hold for 1 day, so I obviously metabolize Coumadin quickly, and it takes awhile for it to build back up in my system.

 

[Guest]

Maybe it makes sense. Some people who use bridge therapy have bleeding. Then the Lovenox is stopped and the warfarin is stopped. Quite often these people then have heart attacks. The people who do the best are the ones who stop the warfarin and use nothing and have no complications. The people with the worst outcomes are those who stop warfarin, use nothing and have a stroke. The people who use bridge therapy usually have outcomes in the middle. That is why I say that choosing bridge therapy or not appears to be not much better than flipping a coin to determine which to use.

 

[Karlynn]

The people who do the best are the ones who stop the warfarin and use nothing and have no complications. The people with the worst outcomes are those who stop warfarin, use nothing and have a stroke.

Maybe I'm just not understanding something, but to me, these two sentences seem to have a "well.. duh!" ring to them. It seems to be a Hind Sight is 20/20 statement. Of course the best case scenario would be to stop Coumadin, use nothing and have no complications and the worst case scenario would be to stop it, use nothing and have a stroke. It seems like in light of being unable to predict what is actually going to happen to a great sense of certainty, or even a small sense of certainty, they just had to state the obvious.

But since my mitral valve makes me "high risk" - I'll roll my dice while on bridging, when I need to.

 

[warrenr]

bottom line

bottom line

I think the bottom line here is the fact that to many doctor's/dentist's have patients stop coumadin for just about any procedure and most of the time don't even check INR before having patient stop coumadin. Some bridge some don't bridge and a lot of the bridging is not needed because the coumadin should not have been stopped to begin with. ie. low bleed risk procedures. I will make an educated guess and say that a very high percentage of patients that are bridged should not have had coumadin stopped to begin with. If doctor's would just follow proper protocols's and perform procedures with patient fully anticoagulated when written standard's dictate such measures, the amount of bridging would probably be cut by at least 25%.

If you are going to have a procedure and you are told to stop coumadin with or without bridging, research the "periopertive anticoagulation management protocol" for the procedure and if the doctor/dentist is wrong show them the written protocol's. If they refuse to follow the protocol, get a new doctor/dentist. If they don't follow proper anticoagulation protocol It makes me wonder what else they don't follow protocol' for.