Risks of Bridging Therapy?

[ALCapshaw2]

From previous posts, I'm well aware of the Risk of STROKE when going OFF Coumadin for Invasive Procedures.

Before undergoing an Upper Endoscopy (and probable biopsy) AND Colonoscopy using Bridging Therapy I'd like to know the risks associated with Lovenox Bridging, including stroke risk during the period when there is NO anti-coagulation, and the risks specific to Lovenox (or Heparin). I know, I'm being paranoid, but I'd also like to be prepared.

'AL Capshaw'

 

[Dennis S]

Very good question

Very good question

I am wondering the same thing. Do these procedures expose you to a risk that is greater than just skipping the whole thing if you don't have concerns from a bad family history, etc.

 

[Ross]

Boy you don't ask much do ya?

Definately an Al Lodwick question.

 

[EVELYN]

Hi Al

If you had just said endo/colo, I would have said try try try to have it done on warfarin. However, you said the words "probable biopsy," which throws another slant on it. This is DEFINITELY an Al question.

I do know that Tyce is having his colo done in October fully anticoagulated. His pcp and gastro have agreed and he will have it done NOT going off the warfarin. However, it is a diagnostic colo only, so if they see something, they'll have to go back in again OFF warfarin. Scary to say the least....

Wishing you the best.....will be following your thread.

Evelyn

 

[Nancy]

You will probably do OK with Lovenox for those kinds of procedures.

Joe had a near death experience with abdominal surgery after being bridged with Lovenox. We believe that Lovenox was partially responsible for his massive bleedout requiring about 33 units of blood products to stop, along with holding his Coumadin and any Heparin for almost 10 days, which was very scary in itself. His recovery was horrible and lasted about 9 months.

I am not saying it was the ONLY reason, but a definite contributor.

It may be that Joe either had impaired kidney function going into surgery or developed kidney problems after this surgery which also might have contributed to the bleedout, since people with impaired kidneys can have an accumulation of Lovenox in their systems, with the potential for bleeding.

The surgery was gallbladder removal.

So if going into any major type surgery have a very candid talk with the surgeon and/or their PAs and anyone else who will be folowing you about checking your kidney function before surgery and during recovery.

I know that Joe will never use Lovenox again. He will use Heparin.

 

[Karlynn]

I know that Joe will never use Lovenox again. He will use Heparin.

Can you explain the difference?

 

[Nancy]

Lovenox is low molecular weight heparin which you can inject yourself at home.

Heparin is IV, done in the hospital, and is easier to control. It does require a longer hospital stay both before the surgery and after until the INR gets into therapeutic range.

By the way, I have recently seen a warning concerning Lovenox and spinal anesthesia. I hadn't noticed that before. Here's the link. Read the red box.

http://www.nlm.nih.gov/medlineplus/druginfo/medmaster/a601210.html

 

[lance]

Warfarin--heparin--lovenox--spinals

Warfarin--heparin--lovenox--spinals

This thread has come at the very best time for me as I'm facing surgery soon.

Nancy--Thanks for posting the link about lovenox bridging, spinals and paralysis. A lovenox bridge with a spinal has been recommended to me.

Warfarin is always the elephant in the living room.

Thanks again and I look forward to A. Lodwick's reply.

 

[Rich]

Al,
I don't know the risks involved with bridge therapy since I've never used it.
Last year I went through the colonoscopy and today I had a gastroscopy done. In each case biopsies were taken.
However the agreement with my doctor doing these tests, was to stop my Coumadin for two days, and not the usual three days that so many insist on.
Another comment I would like to make here is this, if you have to stop your Coumadin the time frame should not be measured in days, but rather in hours.
I say this because it is dependent on what time of day you take your medication, and what time of day the procedure is scheduled for.
For today I backed up 48 hours from the time of the procedure, and took my medication soon after I arrived home.
The point is if you are told to stop three days prior, that could easily end up to be more like three and a half days or even a little longer.
Rich

 

[Guest]

I have talked with several hematologists who have written articles about bridging. Here is roughly the order of things.
Those who do the best no bridging AND no complications
Next best bridging and no complications
Next come those with bridging and complications - they usually bleed and the have warfarin held and then wind up with a heart attack
Worst are those who have no bridging and complications - they usually wind up paralyzed with a stroke.

One of the problems is that there is no standardization of what bridging should be.

Another is that there are no really definitive studies showing that bridging is superior.

Lovenox can be dosed without monitoring for a few weeks for people with normal kidney function. If it does build up it is very hard to reverse. Heparin must be monitored closely and be given by IV in hospitals. It is fairly easy to reverse if needed.

Some doctors say that they never bridge anything but the highest risk of clotting. Others say they bridge everything but the highest risk of bleeding.

 

[Cris N]

Please don't laugh at my naive question

Please don't laugh at my naive question

I am curious about something with the whole bridging (before & after surgery), going off warfarin thing. Instead of taking a patient off warfarin for 3-7 days before surgery, why don't they just drop the INR with oral or injected Vitamin K several hours before (or does it not work that fast) and then use the heparin or lovenox until INR gets back in range with restarted warfarin?

Cris

 

[Nancy]

They used vitamin K on Joe when he had his pacemaker implanted. His doc was going on vacation and he's the one we wanted to do it, so it was done fast. I don't know all the ramifications of doing it that way, but I DO know that it took FOREVER to get his INR therapeutic again. Much longer than ordinarily.

 

[Guest]

Vitamin K is a fat soluble vitamin, so it stay active in your blood for a long time. Heparin does not overcome the effects of vitamin K. It works on a different clotting factor. So you would have to give heparin shots for maybe two weeks until the effect of the vitamin K wore off.

Another alternative is to use fresh frozen plasma. This contains a lot of clotting factors and is used for emergencies. It will drop the INR fast and for a short time but it carries the liability of exposing you to a blood product.

Recombinant Factor VII is another possibility. Its drawback is $$$$$$$$$$$$$$$
Everybody in your insurance plan will have a rate increase if this is used.

 

[Cris N]

I knew there had to be logic to it - seemed too easy. Thanks Al & Nancy for the replies.

Cris

 

[lance]

INR Level when no bridging no complications?

INR Level when no bridging no complications?

Hello Al,

For patients who do best with no bridging and no complications, is it known what their INR level was at the time of surgery AND how many days were they without warfarin?

Can I assume that withdrawing warfarin 5 days prior to surgery without Lovenox bridging and re-instated the day following the surgery (day 7) together with Lovenox injections simultaneously is a safe way to proceed?

Just curious.

I have talked with several hematologists who have written articles about bridging. Here is roughly the order of things.
Those who do the best no bridging AND no complications
Next best bridging and no complications
Next come those with bridging and complications - they usually bleed and the have warfarin held and then wind up with a heart attack
Worst are those who have no bridging and complications - they usually wind up paralyzed with a stroke.

One of the problems is that there is no standardization of what bridging should be.

Another is that there are no really definitive studies showing that bridging is superior.

Lovenox can be dosed without monitoring for a few weeks for people with normal kidney function. If it does build up it is very hard to reverse. Heparin must be monitored closely and be given by IV in hospitals. It is fairly easy to reverse if needed.

Some doctors say that they never bridge anything but the highest risk of clotting. Others say they bridge everything but the highest risk of bleeding.

 

[geebee]

Each time I have had surgery while I was taking coumadin (2 OHS & hysterectomy), I was put into the hospital ahead of time. My coumadin was stopped and I was started on heparin. Just before surgery, the heparin was stopped and I was given plasma to prevent excess bleeding. The coumadin was started right after surgery and heparin was also given until my INR was back in range.

I think this is the same way I would do anything in the future, God forbid it should be necessary.

I have also had 2 other surgeries. One was an exploratory for endometriosis and the other because my OHS scar got infected and I had a lot of infected tissue removed. Both were done while anticoagulated although on the very low end of my range. Plasma was kept at the ready just in case but never needed. If the surgeon does a lot of cautherization there is minimal bleeding (unless he cuts something he shouldn't).