Still bridging with lovenox 11 days after procedure

[kevanndo]

My 11 year old had an upper endoscopy 11 days ago and, per pediatric guidelines at the hospital, was required to bridge with lovenox. My concern is that it's now 11 days after the procedure, and we're still bridging with lovenox because her INR is only 1.9. We can't figure out why it's taking so long for her to get back into her range (2.5-3.5 as she has an MVR). Her cardiologist has had us increase her usual warfarin dose several times this past week, and she's still only inching up ever so slowly. In fact, three days after her dose was increased, her INR actually went down from 1.9 to 1.7. Has anybody had any experience with this? Because she has minimal body fat, I was told to give her the lovenox injections in her thighs, and they're pretty bruised at this point.

 

[W. Carter]

My experiences with bridging have been the same. Each time that I had to bridge it was difficult to get the INR up to range. They should add 10% more on top of her usual dose each week until she is in range. She will need to keep getting injections until she is up to 2.5. It sucks and your stomach gets sore but it is the only safe way.

 

[pellicle]

Hi

My 11 year old had an upper endoscopy 11 days ago and, per pediatric guidelines at the hospital, was required to bridge with lovenox.

from what little I know pediatric cases are hard to manage.

My concern is that it's now 11 days after the procedure, and we're still bridging with lovenox because her INR is only 1.9

.

well bridging with heparins is not harmful, so I would just do it as needed ... its like if you need to shower longer to wash yourself then just do it.

We can't figure out why it's taking so long for her to get back into her range (2.5-3.5 as she has an MVR).

frequently after surgery one's body is busy repairing things. That results in changes in dose, depeding on whats happening and what drugs she is on it could be increase over "normal or decrease. The real point of the matter is this there is no normal dose. Your dose needs to reflect the target INR (3 in your case), that is all there is to it. Clinics and Dr's often get tangled up in things when the core point is that the therapy (anticoagulation therapy) is intended to effect an outcome : that outcome is an INR target.

Her cardiologist has had us increase her usual warfarin dose several times this past week, and she's still only inching up ever so slowly. In fact, three days after her dose was increased, her INR actually went down from 1.9 to 1.7. Has anybody had any experience with this? Because she has minimal body fat, I was told to give her the lovenox injections in her thighs, and they're pretty bruised at this point.

yeah, I hate those injections ... have you tried her but? I was under the impression that the glutes were one of the last muscles to show mass loss when in bed.

I understand their caution in overshooting her INR, it can have complications, but I'd also be taking an approach that W Carter mentioned above, and that is to make dose adjustments in about the 10% range if you are not seeing increase.

How often are you testing, how are you testing?

 

[kevanndo]

I've been testing her every morning using the Coaguchek XS. The first five days after the endoscopy she was taking her usual dose (3 mg or 3.5 mg, depending on the day of the week). This past Tuesday the cardiologist upped her dose to 5 mg. As I mentioned in my original post, three days after this increase, her INR decreased from 1.9 to 1.7. Her warfarin was increased to 5 mg both yesterday and today. She was at 1.9 this morning. I'm hopeful that within two days she'll be near therapeutic range.

I have not tried the injections in her butt because pediatric guidelines specifically state not to use the butt, but to inject near the belly button or the thighs. She is so lean in the belly that there is nothing to pinch, so I've been alternating her thighs.

 

[pellicle]

Hi

I've been testing her every morning using the Coaguchek XS....This past Tuesday the cardiologist upped her dose to 5 mg. As I mentioned in my original post, three days after this increase, her INR decreased from 1.9 to 1.7. Her warfarin was increased to 5 mg both yesterday and today. She was at 1.9 this morning. I'm hopeful that within two days she'll be near therapeutic range.

if you feel like it could you share the dose and INR since she started back on warfarin?

I have not tried the injections in her butt because pediatric guidelines specifically state not to use the butt, but to inject near the belly button or the thighs. She is so lean in the belly that there is nothing to pinch, so I've been alternating her thighs.

interesting ... didn't know that!

Best Wishes

 

[harrietW]

I am all pretty new to this but my experience has also been the same. l was bridging now several times in the last 2.5 mths. Every single time it seems to take about 10 to 14 days to be at therapeutic levels. I would also think butt however l haven't need to for myself as l have plenty of space on my belly right now this time l am on one shot 16,000 previous few times l was on lovenox 2 shots for the better part of 2 mths it really really hurts after awhile. My inr levels took quite a bit to therapeutic range but always seemed to drop a couple point before getting there.
Poor little thing. Best of luck sending hugs Xx

 

[kevanndo]

She had her endoscopy on March 23. I resumed warfarin the next day as well as bridging with lovenox. Below are her dosage and INR each day beginning with March 26. I realized in looking back that I didn't check her INR on March 24 or 25 because I knew she wouldn't be anywhere near in range.


Mar. 26--INR 1.3, warfarin 3.5 mg
Mar. 26--1.3, 3 mg
Mar. 27--1.4, 3.5 mg
Mar, 28--1.7, 3 mg
Mar. 29--1.6, 5 mg
Mar. 30--1.9, 3 mg
Mar. 31-- 1.9, 3.5 mg
Apr. 1--1.7, 5 mg
Apr. 2--1.9, 5 mg

An update from posting the above results earlier this morning: I just checked her INR, and it was 2.7.

 

[pellicle]

Hi

She had her endoscopy on March 23. ...
...
Mar. 26--INR 1.3, warfarin 3.5 mg <--
Mar. 26--1.3, 3 mg

ok, so this was then the 25th? not the 26th?

either way, from what I see in my model assuming it is transferable to a child it would seem to me that continuing at 5mg daily will get her to between 2.2 and 2.8

If you wanted to get her to INR=3 I'd move it up to 6mg daily and see where that leads. If you were to do that I would expect that it would take until the 8th for her INR to peak as a result of the change to 6. I would expect from that (assuming my model works) that INR could be between 2.75 and 3.3 on that dose.

What ever you decide to do I'd be keen to hear the choices and the outcomes ... for my own education.

 

[kevanndo]

I resumed checking her INR on March 26. She was at 1.3 and her dose that day was 3.5 mg (ignore the mistaken second entry for 3/26). Note that after entering all the above results initially, I edited my post later this morning after I checked her INR today, and it was 2.7! Quite an increase since yesterday's 1.9. The irony is that now I'm concerned about her INR going too high after upping her dosage the past three evenings, the effects of which probably haven't been seen yet (at least the increased doses of the past two evenings). Her cardiologist shares my concern and advised me through email to hold her dose tonight and resume her normal schedule (3-3.5 mg) tomorrow. I'll let you know how all this plays out.

 

[pellicle]

Hi

... INR today, and it was 2.7! Quite an increase since yesterday's 1.9.

consistent with my expectations

The irony is that now I'm concerned about her INR going too high after upping her dosage the past three evenings, the effects of which probably haven't been seen yet (at least the increased doses of the past two evenings).

a valid concern ... please PM me with your contact details if you wish, I'd find helping you much easier with a better communication channel.

Her cardiologist shares my concern and advised me through email to hold her dose tonight and resume her normal schedule (3-3.5 mg) tomorrow. I'll let you know how all this plays out.

if by HOLD the dose you mean "skip a dose" I caution you do not do that it will more than likely set up a see saw effect where you'll spend more and more time trying to stabilise. I find it strange that people discuss stabilisation of INR while essentially being willing to rock the boat. It is illogical to me.

I would instead suggest 4 and see ... my model suggests that would keep you under 3 .. please state again what your desired range is for confirmation, is it not 2.5 to 3.5?

If that is correct then you are now perfectly in range, a sudden ceasing of warfarin will not help you keep it there and there is no reason to panic because you have been inching up with doses.

I think you may just be "losing your nerve" which is understandable. But honestly unless your daughter has a history of bleeds even INR=4 is not regarded as dangerous.

Its your call.

Lastly I have one clarification question. My data shows 2nd April as being INR=1.9 and 3rd April as being INR = 2.7 I know the dose given on the 2nd as 5mg, is this correct? I would like to incorporate the dose from the 3rd.
When do you take the pill (am or pm) and when do you check INR?

 

[yotphix]

You're getting all the help you need, it seems, but I'm inclined to add my 2 cents to the thread. When I started ACT, I had doctors timidly prescribing tiny increases from my initial 2, then three mg daily, and with this wacky notion that I should have three different doses through the week, to give me a weekly total that in their minds would get me to hit the target. To me, that seemed a bit like trying to swat flies with spaghetti noodles. It also failed completely. Since I began to manage myself, I've been out of range only twice, and with reasonable explanations, and I've always worked out a dose that could be the same every single day. (At 11mg daily now, mind you!)
If your testing frequency is daily, and you're changing doses by as much as 50% day by day, what are the chances that you'll have a stable, in range INR on every test? Previous experiments discussed in these fora, and my own experience suggest that those chances are not very good.

 

[W. Carter]

If you wanted to get her to INR=3 I'd move it up to 6mg daily and see where that leads. If you were to do that I would expect that it would take until the 8th for her INR to peak as a result of the change to 6. I would expect from that (assuming my model works) that INR could be between 2.75 and 3.3 on that dose.

That is a pretty accurate model for dosing. My weekly dose is 45 mg and my INR usually runs at 3.0 consistently. But like you said we are adults so who knows for children.

I imagine when her INR gets into range like it is now she will continue at her dose prior to her procedure. It seems low dosing to get in the 2.5-3.5 range but she is a kid and that probably makes a difference.

Take care guys and good luck!