Lovenox?

[Guest]

I agree about the protocols, but some protocols are out of date. We have learned in the past year that many outcomes on bridging are worse than expected. The field is changing so fast that protocols that are written in January and published in July are in danger of being outdated before they see the light of day. This is why there is so much confusion over this topic.

 

[catwoman]

I just spent the weekend with a 53YO woman who had a stroke about 4-5 years ago. This was unrelated to any prosthetic valve or going off warfarin (she's never taken it). There is a history of strokes in her family.

My friend has memory gaps at times, has limited use of one side of her body. I knew her before her stroke, so I can discern the difference in her life. She's still bright and has a lot to offer the world, but unfortunately, she can no longer practice law or be a hospital laboratory technician (her occupation before going to law school).

Thank you very much, but I'll opt for Lovenox over no protection whatsoever.

 

[Marty]

From Dr Lefrak

From Dr Lefrak

Marty, The absolute safest thing to do.....and we do it before major surgery, is to stop the Coumadin 4 days before surgery (knowing the INR is above 2.5 before discontinuing the oral drug) and then admit the patient a day (or possibly 2 ....depending on the INR) later and use IV unfractionated heparin.......a pain in the neck for the patient, but very safe. For lesser procedures, in which there is little or no bleeding risk, it would be ok to stop the Coumadin 2 days before, then do the procedure, eg., colonoscopy (with and INR that has not gone down to baseline) and then resume the Coumadin the night of the procedure (the last maneuver is dependent on KNOWING that the INR is above 2.5 before stopping the Coumadin. ( Many people on Coumadin still have an INR that is too low.) Ed

Dr. Lefrak is the founding Chief of cardiac surgery at Inova Fairfax Which does over 2000 hearts each year. He also wrote a book on mechanical valves a few years ago. In the PDR ,Aventis says Lovenox has never been adequately studied for use in thromboprophylaxis for mechanical prosthetic valves. There have been isolated reports of thrombosis in mechanical valves in patients being given Lovenox for prophylaxis.

 

[Karlynn]

My question would be to Dr. Lefrak - If the procedure had little or no bleeding risk, why stop the Coumadin at all? As accomplished a doctor as he is (and I'm sure he is, as well as caring) he appears to be in the group of the majority of doctors who fear bleeding more than stroke - if he would have someone stop Coumadin for a procedure with little or no risk for bleeding.

I also question the protocol of when to stop Coumadin. (Not a comment on Dr. Lefrak, just a general observation) Telling someone who's on 5 mg a day will drop slower than myself, who is on 9 and 10 a day. So to tell both of us to stop 4 days before (or whatever amount) would mean that I would be nontheraputic for a longer time than the 5 mg person, so the protocol places me at greater risk.

 

[warrenr]

Dr. Lefrak

Dr. Lefrak

Though I don't totally agree with Dr. Lefrak (He is the cardio) he mentions something very important here.

Marty, The absolute safest thing to do.....and we do it before major surgery, is to stop the Coumadin 4 days before surgery (knowing the INR is above 2.5 before discontinuing the oral drug) and then admit the patient a day (or possibly 2 ....depending on the INR) later and use IV unfractionated heparin.......a pain in the neck for the patient, but very safe. For lesser procedures, in which there is little or no bleeding risk, it would be ok to stop the Coumadin 2 days before, then do the procedure, eg., colonoscopy (with and INR that has not gone down to baseline) and then resume the Coumadin the night of the procedure (the last maneuver is dependent on KNOWING that the INR is above 2.5 before stopping the Coumadin. ( Many people on Coumadin still have an INR that is too low.) Ed

It appears that Dr. Lefrak will not proceed without first knowing the INR and then he determines when to stop and or restart coumadin. This is such a major factor that a lot of doctor's overlook. You have to know were to start in order to get to the destination. Hat's off to Dr. Lefrak

 

[Marty]

Heparin for me

Heparin for me

OK, I think I've learned something from all this enlightened discussion. If I needed a cholecystectomy or a hip replacement I would bridge in hospital with heparin. I would not stop warfarin before colonoscopy but would tell the GI if he found something that required cutting to reschedule a second colonoscopy and would bridge with heparin. While there have been no controlled evidence based studies with heparin , it has been used for over 60 years. None of us have ever heard of valve clotting in a heparinized patient.We all know of Lovenox failures and Aventis acknowledges this in their package insert.

 

[Karlynn]

Somewhere on this site someone gave reference to something that said that a few polyps can be removed during a colonoscopy on an anticoagulated patient. Don't have time to do the hunt right now, but I can later. So I guess, depending on what is found, sometimes the issue can be taken care of at the same time as the colonoscopy.

 

[Nancy]

Marty-

I like your plan.

 

[Marge]

I have been reading this thread with interest because I think it is likely that my PCP may suggest I have a colonoscopy at some time in the near future. I've never had one.
I did have a sigmoidoscopy once but it was over 10 years ago.
I guess I should have talked to my doctor about doing a colonscopy before this A-flutter thing showed up and I was started on coumadin. But how was I to know?
Anyway, I have been trying to read up on this subject. It seems the risk factors of actually not being on anticoagulants do differ depending on the reason you're on the coumadin in the 1st place -- very high if you've got a mechanical, with the risks varying according to various factors if you are taking coumadin for other reasons. In my case, as I said, it's for atrial flutter. Never have had a stroke, not even a TIA. Risky?
I read Marty's solution -- have the colonoscopy while fully coagulated, but then have a second colonoscopy if polyps showed up & cutting were required. But I don't like the idea of two of the damn things.
Actually the colonoscopy might not be so bad. I just took a friend to have one done, and they fed her so much Versed she has absolutely no recollection of it and was fine afterwards -- we went out & had coffee on the way home -- but I would dread undergoing the "preparation" more than once.

 

[ALCapshaw2]

None of us have ever heard of valve clotting in a heparinized patient. We all know of Lovenox failures and Aventis acknowledges this in their package insert.

Other than Joe's near bleedout due to intermittent kidney failure (and a local bleed by someone on Lovenox and Plavix) and the infamous Pregnant South African women's study, can you tell us of other Lovenox failures? The story I hear from my Doctors is that there have been no problems with Lovenox Bridging.

'AL Capshaw'

 

[Guest]

I don't know how they could say no problems. A fairly good percentage wind up bleeding and having all anticoagulation stopped. Then some of those people have heart attacks. There is nothing in medicine that causes "no problems".

 

[Karlynn]

A fairly good percentage wind up bleeding and having all anticoagulation stopped.

What percentage would that be?

 

[ALCapshaw2]

Question for AL Lodwick (or anyone else who chooses to respond):

If YOU or a family member were on Coumadin and needed a GI Procedure (Endocsopy or Colonoscopy) and there was a good chance that a Biopsy would be justified, what would you do or recommend for your family member in regard to holding anti-coagulation (or not) and whether you would recommend Bridging (and which type).

'AL Capshaw'

 

[Guest]

There is no money to do a big study to learn the exact percentage. The reason there is no money is that Lovenox has the biggest share of the world market. Any negative result would hurt market share. Therefore, the company will not fund the research. No governmental agency has the authority to demand this when a drug has already been approved for sale.

I would do the bridging. I am more of a play it safe person than an all or nothing gambler. The outcomes of bridging tend to center on very good to fair. Not bridging gives excellent or very poor outcomes.

I would use Lovenox 1 mg/kg (about 1 mg for your weight in pounds divided by 2) every 12 hours starting one day after warfarin was stopped and continuing until the INR was above 2.0 or 2.5. This is expensive and assumes that you have insurance that will cover it. Many insurance plans will not. Lovenox does have an assistance plan for those who cannot afford it.

 

[warrenr]

Asge 2005

Asge 2005

Question for AL Lodwick (or anyone else who chooses to respond):

If YOU or a family member were on Coumadin and needed a GI Procedure (Endocsopy or Colonoscopy) and there was a good chance that a Biopsy would be justified, what would you do or recommend for your family member in regard to holding anti-coagulation (or not) and whether you would recommend Bridging (and which type).

'AL Capshaw'

Al,

This was published by the ASGE standard of practice comittee in 2005

http://www.asge.org/nspages/practice/patientcare/heparinProcedures0205.pdf

 

[warrenr]

biopsy

biopsy

Somewhere on this site someone gave reference to something that said that a few polyps can be removed during a colonoscopy on an anticoagulated patient. Don't have time to do the hunt right now, but I can later. So I guess, depending on what is found, sometimes the issue can be taken care of at the same time as the colonoscopy.

Karlynn,
I think this is what you are talking about. If not let me know and I will find it>

Elective Endoscopic Procedures in the Anticoagulated Patient
http://www.asge.org/nspages/practice/patientcare/anticoagulation.cfm#PageLink01

Procedure risks
Endoscopic procedures vary in their potential to produce significant or uncontrolled bleeding. Low-risk procedures include diagnostic esophagogastroduodenoscopy (EGD), flexible sigmoidoscopy and colonoscopy with or without biopsy, diagnostic endoscopic retrograde cholangiopancreatography (ERCP), and biliary stent insertion without endoscopic sphincterotomy, endosonography (EUS), and push enteroscopy. High-risk procedures include those associated with an increased risk of bleeding such as colonoscopic polypectomy (1%-2.5%),6 gastric polypectomy (4%),7 laser ablation and coagulation (less than 6%),8,9 endoscopic sphincterotomy (2.5%-5%),10 and those procedures with the potential to produce bleeding that is inaccessible or uncontrollable by endoscopic means such as pneumatic or bougie dilation of benign or malignant strictures, percutaneous endoscopic gastrostomy, and EUS-guided fine needle aspiration.

 

[Guest]

My point about the lag time is that something that was published in 2005, probably is the result of a meeting in 2004 and maybe the cutoff date for articles to be discussed was January 2004. Anything learned in the last 18 months or so will not be in the guidelines. The people who set these things are top "names" so it takes months just to get the thing on everyone's calendar. Then there is the lag time in getting everyone to agree on the final draft and then it gets into the publication pipeline and it has to be proofread again. When a guideline gets published it may already be out of date. It isn't automatically out of date and useless but it needs to be looked at in light of new developments.

I looked over the guidelines. They are based on publications from 1987 to 2003. So they do not include anything newer than 22 months old.

Look at your own life (or job) and imagine trying to do everything just as you did 18 months ago.

 

[Marty]

I have been reading this thread with interest because I think it is likely that my PCP may suggest I have a colonoscopy at some time in the near future. I've never had one.
I did have a sigmoidoscopy once but it was over 10 years ago.
I guess I should have talked to my doctor about doing a colonscopy before this A-flutter thing showed up and I was started on coumadin. But how was I to know?
Anyway, I have been trying to read up on this subject. It seems the risk factors of actually not being on anticoagulants do differ depending on the reason you're on the coumadin in the 1st place -- very high if you've got a mechanical, with the risks varying according to various factors if you are taking coumadin for other reasons. In my case, as I said, it's for atrial flutter. Never have had a stroke, not even a TIA. Risky?
I read Marty's solution -- have the colonoscopy while fully coagulated, but then have a second colonoscopy if polyps showed up & cutting were required. But I don't like the idea of two of the damn things.
Actually the colonoscopy might not be so bad. I just took a friend to have one done, and they fed her so much Versed she has absolutely no recollection of it and was fine afterwards -- we went out & had coffee on the way home -- but I would dread undergoing the "preparation" more than once.

Marge, I see you are a Kaiser patient. At my Kaiser clinic in Falls Church VA the GI's do bridge with Lovenox in about the same protocol that Al described. Having had a repair rather than a mechanical valve you should do just fine. Marty