nose surgery and coumadin

[mile high]

Next week I will be having surgery on my nose to remove basal cell cancer. The procedure used will be the Mohs procedure. In discussing this with the surgeon and with my cardiologist I have not really received any consensus on my coumadin regimen prior to the surgery. The face has so many capillaries that bleeding is a concern anytime you cut your face. My cardiologist has said I could be off of coumadin for up to two weeks if I want. the surgeon says talk to the cardiologist.

In any case I am thinking I will stop the coumadin two days before surgery, the day of surgery and two days after surgery, so a total of 5 days. My INR's are always in the 2.5 to 3.5 range.

Any thoughts?

If anyone needs info on skin cancer and surgery, let me know. I have studied this just the like the whole heart thing. This is my second surgery for this, both on my nose. The first was before my heart surgery.

Thanks

 

[Karlynn]

My cardiologist has said I could be off of coumadin for up to two weeks if I want. the surgeon says talk to the cardiologist.

I really don't know what to say to that. I'm in such utter shock!!! The first thing I'd do is get a new cardiologist. He/she obviously has no idea what he's talking about. You have a mechanical valve and his/her lack of knowledge could have taken your life.

I would first - ask Al
2nd - ask the surgeon to check the SOP (standard operating procedure) for coumadin with this procedure that is prescribed by his/her college or professional organization (not knowing exactly what type of surgeon he/she is.)
3rd - look up posts under member's name Warrenr. His father suffered a massive stroke after being off coumadin for 3 days prior to a routine colonoscopy (for which the GI college doesn't require in their SOP)

If this can be done without stopping coumadin, that would be best.
If coumadin must be stopped, then a bridging therapy must be used to keep you anti-coagulated up until the last possible minute before the procedure and then back on the bridging therapy immediately after the procedure.

We have many members who have had successful procedures requiring bridging therapy and I'm sure they'll hop on here to tell you about them.

 

[mile high]

Karlynn,

Thanks for the reply. Possibly a dumb question, but you mentioned "Al" in your response. Who might that be.

Mile High

 

[JimL]

Al in this case is Al Lodwick.

I needed some skin surgery done, just over a year ago. It took a while to find a surgeon who would do the surgery while I remained on coumadin. They did an INR right before the surgery, just in case I was really high. Otherwise, the surgery went fine. There was no excessive bleeding.

My other alternative was to be admitted to the hospital for a week, so that my anticoagulation needs would be covered by heparin instead of coumadin. I didn't really have a week to spare (although the vacation time would have been nice). But I also felt far safer remaining on coumadin.

I assume that when you stop coumadin you would immediately start up either heparin or lovenox. I don't know what risk of bleeding there is with your nose surgery. There definitely are different thoughts regarding coumadin and surgery. One doctor's standard operating procedure might not be in your best interests. I encourage you to keep checking to be sure before you have the procedure. Staying on coumadin, if that is possible, is by far the safest method -- at least, that was my conclusion in my case.

 

[Karlynn]

Mile High,
As Jim mentioned Al is Al Lodwick. We are so very blessed to have him as a member here. He is a warfarin (Coumadin) expert that has his own clinic. He knows more about the management of this important drug than most doctors. I encourage you to visit his site www.warfarinfo.com .

How often do you get your INR checked? I ask this because it sounds like your cardiologist might not be monitoring your INR in the way it should be. It's usually a once a month test if your INR is stable. Mine doesn't like to be, so I monitor it every 2 weeks with my home testing unit. Right now my INR is a bit too low (I've increased my exercise program, which will lower it.) So I've been testing once a week for the last few weeks.

There are, unfortunately, too many of us here who have found out the hard way that there are doctors out there that don't have the knowledge required to treat our issues. So finding our own information is the best proactive way to make sure we have physicians that have the expertise to care for us. At my last cardiologist appointment I did a little Q & A with her on Coumadin just to double check if she was on the page she needed to be on.

Sorry if I sounded harsh in my last post - that 2 week thing really almost knocked me off my chair.

 

[catwoman]

Mile High:

Al Lodwick is a pharmacist and a certified anticoagulation care provider (I think that's the correct term) at a hospital in Pueblo, CO. If MILE HIGH refers to your living around Denver, you might want to schedule a private consultation with him.

Yesterday I printed out a copy of "When patients on warfarin need surgery," published Nov. 2003 in the Cleveland Clinic Journal of Medicine. I think I found it under REFERENCES here on vr.com.
Under dermatologic procedures, it states, "Dermatologic procedures that have been performed safely without stopping warfarin include Mohs micrographic surgery and simple excisions and repairs."
Check it out and look for protocols/suggestions for using bridge therapy of low-molecular weight heparin (Lovenox, etc.).

 

[csutherland]

skin cancer/anticoagulation

skin cancer/anticoagulation

Jerry has had at least 3 skin cancers since his AVR. The first was basal cell on the top of the ear, with skin grafting. Then a squamous cell that went pretty deep into the tip of the nose, followed by another basal cell on the lip. You can probably find them in my past posts, and I can't remember every detail, but don't believe anything was needed in the way of warfarin adjustment. The mohs procedure was used each time. There certainly wasn't any problem with excessive bleeding.

Hope this helps.

 

[mile high]

Thanks everyone for the info. We all have to be our own best health advocates so your experience becomes all of our experiences. It makes us smarter patients. It is what valvereplacement.com is all about.

Celia, thanks for the first hand experience info on Jerry's surgeries for skin cancer. It is good to know he did not alter his coumadin regimen and that everything turned out good.

Marsha, I found the article at the Cleveland Clinic. It is an excellent article for anyone who might be having surgery and I found the reference to Moh's procedure. Thanks that was excellent.

Karlynn, this forum is for people to speak their mind and you did. Keep that up. I have my INR tested anywhere from every 4 to 5 weeks. It generally depends on the most recent result as to how long they will wait to do the next one. Since I have mostly kept my INR's in the cardioligist's range for me of 2.5 to 3.5, it has rarely been more frequent than that.

I do have to say that the I do not completely understand what the INR test is actually testing. Stay with me on this. My wife is a long time insulin dependent diabetic who is on the cutting edge of blood testing for glucose levels. In the case of a diabetic, the blood glucose tests she does during a day measure blood sugar levels at that moment. She adjusts her insulin use right then if needed. I believe that is what INR tests are also doing that is testing at that particular moment. I understand that our INR may not fluctuate wildly during the day like an insulin dependent diabetic. However, we as coumadin users do not know if it is going up or down, we just know what it is at that particular moment. Being tested every few weeks or even once a week I wonder what good it really does again except to tell us what it is at that moment. Any thoughts on that?

Again thanks for the help everyone. I am still figuring out what to do and have recontacted my cardiologist and the Mohs procedure surgeon and of course read the info you all have provided. Any more helpful thoughts, feel free to provide them. My surgery is on Tuesday, I will let you know how it all turns out.

 

[Marty]

I had a malignant melanoma excised from my abdomen a few months ago. It was a pretty long deep cut. My dermatologist did not advise stopping the coumadin. The wound healed well with no complications. I tested INR 3.0 the day before the surgery.

 

[JimL]

I do have to say that the I do not completely understand what the INR test is actually testing. Stay with me on this. My wife is a long time insulin dependent diabetic who is on the cutting edge of blood testing for glucose levels. In the case of a diabetic, the blood glucose tests she does during a day measure blood sugar levels at that moment. She adjusts her insulin use right then if needed. I believe that is what INR tests are also doing that is testing at that particular moment. I understand that our INR may not fluctuate wildly during the day like an insulin dependent diabetic. However, we as coumadin users do not know if it is going up or down, we just know what it is at that particular moment. Being tested every few weeks or even once a week I wonder what good it really does again except to tell us what it is at that moment. Any thoughts on that?

I think you've got it right. An INR test result of 3.0 means that your INR at that moment is 3.0. But the test results would be identical if your INR was steady at 3.0, falling from 4.0 to 2.0, or climbing from 2.0 to 4.0. That's why consistency is so important, both consistency in diet and consistency of dosage from day to day. I keep all my dosages and INRs in a little booklet, so that I can look back and see where I've been, which helps predict what dosage will be correct for the next week.

 

[ALCapshaw2]

Bridge Therapy is where you go OFF Coumadin but take a shorter acting anti-coagulent up to around 8 hours before (and then again after) the invasive procedure.

There are 2 alternatives.

Lovenox injections which you can administer yourself at home. There were some complications with a few pregnant South African women several years ago but it is *assumed* they forgot to take their weight gain into consideration when dosing. NO problems have been reported in the USA to my* knowledge. (Do you have me* confused with AL Lodwick, the Coumadin Clinic Director in Colorado?)

Heparin drip (considered to be safer) but requires administration at the hospital, typically for 3 days before and 3 days after (until normal INR is achieve following surgery). It is stopped 8 to 12 hours before the procedure and resumed at some (to be determined) time after the procedure and is continued until your INR is back in range as you also resume your Coumadin therapy. And NO, most hospitals do NOT do the finger stick testing so you get to have your blood drawn every 6 or 8 hours.

'AL CAPSHAW' AVR / Coumadin patient in Alabama

 

[Marty]

Jim, I like Al Lodwicks characterization of the INR. He says trying to keep it steady at lets say, 3.0 is like taking a long car trip and at all times keep your gas tank half full!

 

[KristyW]

JimLI think you've got it right. An INR test result of 3.0 means that your INR at that moment is 3.0. But the test results would be identical if your INR was steady at 3.0, falling from 4.0 to 2.0, or climbing from 2.0 to 4.0.

Not only that Jim & Mile Hi, but coumadin stays in the bloodstream for 6 days from when you take the dose, so...to complicate matters more the INR reading of 3.0 at this moment really is testing your dose from 3 days ago!!! Talk about a nightmare to figure out!

Jim is right though, consistency is the key. Check out Al Lodwick's site, read the posts in this forum. Most of all, be your own advocate. If your cardio or surgeon balk at the things you want to do, ask them why? I've butted heads with my pcp more than not, but he eventually agrees to do things my way as far as coumadin once I've given him my research and evidence.

Good luck!

 

[bvdr]

Hi Mile High,

I had Mohs surgery for squamous cell CA of the upper lip in March and I did not come off coumadin and had no problem with bleeding. The cancer was both on the cutaneous skin above the lip and the red part of the lip which is very vascular too. I went through the procedure 4 times and then he cut out a wedge from my nose to my lip and across the upper edge of my lip to the corner and realigned and resected the area. I had no bleeding problems whatsoever. I had more bleeding with the biopsy than I had with the Mohs surgery and repair. The cosmetic results are great. You have to look closely to detect the scars.

I had the Carac (5-FU) chemotherapy for 3 weeks over pretty much my whole face recently as a follow-up. During that I did have some oozing of blood as the pre-cancerous areas died and sloughed off. It only affects the effected areas so the more it reacts the more you know it is working which is some consolation for the discomfort of the chemo. But with that too, there was no need to alter my coumadin. I think it probably oozed a little more than it would have otherwise.

I wish you the very best with your surgery and if they will do it without you coming off coumadin then I think that is what you should really consider doing.

 

[Karlynn]

However, we as coumadin users do not know if it is going up or down, we just know what it is at that particular moment. Being tested every few weeks or even once a week I wonder what good it really does again except to tell us what it is at that moment. Any thoughts on that?

I agree. I think this is why most of us like to stay on the middle or high range of our theraputic levels. We know from Al that he rarely sees bleeding issues with anything at 5 or lower so I worry more about the low readings. Mine was 2.2 this week, 2.1 last week and I know why. But I didn't bump up my dose too much because I can also swing my numbers like crazy. Right now I take 9 4 days a week and 10 3 days. Sounds like a lot. I must have a very healthy liver.

It will be interesting to see how INR testing progresses. I'm jealous of how my daughter's friend next door has a glucose monitor that fits in the palm of her hand and my ProTime is a big ol' thing. Glucose monitors keep getting smaller, more portable and cheaper. I'm hoping the same will happen with INR monitors.

 

[Nancy]

Like Karlynn-

I too am in shock at your cardiologist's cavalier attitude regarding Coumadin. And more in shock that they seem to be leaving you to your own devices as to what to do about your Coumadin. That's unprofessional, and makes me think that your cardiologist doesn't understand Coumadin very well, and skipped the lecture on bridge therapy.

It is dangerous for you to go off Coumadin without someone monitoring you and giving you some type bridging medications such as Lovenox or In-hospital IV Heparin.

My husband had a basal cell carcinoma removed w/o going off Coumadin and he also had a squamous cell carcinoma removed w/o going off Coumadin.

The only problem he had was when the scab came off too soon, and he did have quite a bleeding episode. I had to take him to the ER.

 

[Sierra Bob]

I had a BCS removed a few months ago. It was on my lip and extended into my right nostrill. It was 5/8" x 1/4" x 1/4". I did not go off Warfarin and my target is 3.5 INR. I had no problem with bleeding. NONE. Sierra Bob

 

[tommy]

Mile High,

I had a wide area excision (forearm) and sentinal node biopsy 2 years ago. Initially the surgeon said the he would prefer (soft language) that I not be on anticoagulants for the procedure. But it didn't take any arm twisting to change his mind. My cardiologist and the surgeon talked directly and came up with a strategy to skip 1-2 doses of coumadin prior to the procedure (sorry, I don't remember the actuall number of doses skipped).

Blood was drawn for an INR about 1 hour before the excision procedure, but when the lab was slow with the results, the surgeon went ahead without it (he was not concerned). Later we found out that it was about 2.0. I resumed Coumadin that evening with normal dose.

For some procedures such as skin "cuts" and dental work, the anticoagulants make the procedure less convenient for the doctor and also can cause more bruising for you. These are not strong enough reasons to stop the anticoagulants (my opinion). You see, anticoagulants don't make you bleed faster, they just make you bleed a little longer.

Regarding stopping Coumadin for 2 weeks, it is difficult for me to communicate just how far off base that advice is. First, it is bad medicine. It's just plain wrong. Second, the time frame is ridiculously long. Coumadin absorbs in 3-6 days. I see this error from other specialists, but not from cardiologosts. It my cardiologist that straightens the other guy out.

I have had Lovenox "bridges" several times for other procedures and surgeries - hernia and colonoscopy. In each case, my cardiologist spoke directly with the other specialist and took the lead role in determining the anticoagulant strategy.

Hope this helps.

 

[Nancy]

Regarding holding Coumadin for 2 weeks. I believe that Coumadin has a half life of 36-42 hours. So if you hold for 2 weeks, you can plainly see that you will be totally unprotected for many days. That puts you at an unexceptable risk of clotting which could cause a stroke or ruin your heart valves. Could even cause death.

 

[Karlynn]

I think another important reason to dispell the bad information of going up to 2 weeks without Coumadin, is travel. We don't want people to think that if they take off for vacation, or head out on a business trip and forget their medication, that it's okay because they'll return in a week and start it again. When we went to Paris I took 16 days worth of medication for an 8 day trip. I carried enough in my purse to last 8 days, and I had enough in my luggage to last 8 days. I always carry 2 days worth in my purse at all times.