Going off Coumadin

[RandyL]

I will be stopping my coumadin on June 1st to have an epidural procedure June 5th. I plan on starting my coumadin right after the procedure unless someone here says different. Do I go back to my normal dosage of 10mg per day or do I take more at first. I also have 5 Lovenox injections leftover from coming home after surgery. They are 60mg shots. Should I take them also? Looking for some advice. Thanks

[Ross]

Randy I'm going to leave this one for Al. Epidurals are not the ones for me to answer on. He may be a bit getting here, but please be patient or PM or Email him about it. ;)

[JimL]

I've had three cysts removed since I went on coumadin for life -- I'm not sure if that's the same kind of surgery you're having or not. I searched and found a doctor who would do the surgeries while I stayed on coumadin. The first I had general anesthetic, the last two just local. I had no problems at all on the bleeding front.
If it would help, I could share the doctor's name and phone; perhaps he can recommend someone in your area. PM me.

[Lynlw]

with epidurals the problem is even a drop of blood could paralyze you. randy you have been in my prayers, I know how awful back pain is and you've been dealing w/ this for a while now, I hope it brings some relief, Lyn

[RandyL]

Thank you Lynn

Jim I am geting a epidural steroid shot for my back pain. I have a herniated disc at L4 and the chiropractors have not been able to help me so this is the next step. If this doesn't work than I am researching the lazer back surgery they have now.

Ross I question is really about coumadin. I already know the risks of the epidural, I just need some advice on how to handle my coumadin.

[Lynlw]

I have one of these implanted, http://www.ans-medical.com/patient/basicsofscs/index.cfm

honestly it really doesn't help much but worked well the first couple years, but i don't know if they could put on in a patient on coumadin, lyn

[bvdr]

I will be stopping my coumadin on June 1st to have an epidural procedure June 5th. I plan on starting my coumadin right after the procedure unless someone here says different. Do I go back to my normal dosage of 10mg per day or do I take more at first. I also have 5 Lovenox injections leftover from coming home after surgery. They are 60mg shots. Should I take them also? Looking for some advice. Thanks

Follow your doctor's instructions. When I had my cervical epidural I started my coumadin that night and I think used the first Lovenox after 12 hours. I have read that loading doses of coumadin are not really used much anymore. Your doc will probably have you start back at your regular dose and by the time your lovenox are finished you should be good to go. Do find out how your doc wants to handle this though and this isn't like having most procedures since bleeding in this case can be really serious. I hope you get good results with your epidural.

[ALCapshaw2]

Talk to your CARDIOLOGIST, ASAP.

Ask if your REALLY need to go OFF Coumadin for this procedure.

Then ask if you should go on BRIDGING THERAPY (Lovenox) while you are off Coumadin. Whoever manages your Coumadin should also be able to manage the Lovenox protocol.

Bottom Line: Let the PRO's call the 'shots'!

'AL Capshaw'

[RandyL]

Talk to your CARDIOLOGIST, ASAP.

Ask if your REALLY need to go OFF Coumadin for this procedure.

Then ask if you should go on BRIDGING THERAPY (Lovenox) while you are off Coumadin. Whoever manages your Coumadin should also be able to manage the Lovenox protocol.

Bottom Line: Let the PRO's call the 'shots'!

'AL Capshaw'

Well Al, the way I see it I am asking the pros. When the lab called my Cardio they gave the instructions of "Stop taking coumadin 5 days before epidural procedure" and those are the only instructions I have. I have little or no faith in my Cardio in regards to coumadin. Every decision his office has ever made concerning coumadin has been wrong. I don't believe he has an understanding of the drug as far as dosing goes because his decisions have not been in line with the experts on this forum. I have Al's chart and I follow it religously and I have been in my range all the time(2.0-3.0) btw which is not what my Cardio wanted. He wanted me to be within 2.0-2.5 which is about as ridicoulous as he not signing off on my home test machine(had to get it through my primary Doctor).

So any advice here is very appreciated since it is the advice I believe in and will follow.I will be going off the coumadin, I just want to know which is the best way to start back up. Like I said in my previous post I do have a prescription for Lovenox from my surgery and could use it after the procedure if you all think I should and also Should I take my normal dose of coumadin the night of the surgery?

Thanks Again. :)

[geebee]

Randy,
I fear for anyone who needs to go off coumadin but I also understand back pain so I feel for you also.
Since the danger of bleeding for the epidural should cease the minute the epidural is over, I should think you can go back on coumadin right after the procedure since it will take a couple of day for you to be back in range. I would also consider lovenox until you are back in range. If the lovenox you have has not expired and you feel you have enough to get you back in range, I do not see any reason not to use up such an expensive drug. However, you should make sure your doctor is aware you are using it. He should also be able to tell you when to start the lovenox.
As far as the amount of coumadin to take after the procedure, I would just take my normal amount as it takes so long to work I don't think doubling would jump start things and it could cause your INR to yo-yo.
Best of luck to you.

[PJmomrunner]

However, you should make sure you doctor is aware you are using it.~Geebee

And now...from the peanut gallery...:D

I understand that you don't trust your cardio re: coumadin therapy, but I really think you should ask enough questions (particularly of the person doing the epidural) to gain confidence that your ACT is being properly managed so as to avoid both clotting and bleeding problems. Much searching the web and PubMed has turned up lots of uncertainty and controversy regarding ACT and epidural anesthesia.

The info seems to refer to epidurals during surgeries, not for administration of medication for back pain, but it seems that the crucial times for complications (hematoma resulting in spinal compression, etc.) seem to be when the needle is inserted and when it is removed. If I read correctly, care needs to be taken to monitor the level of anticoagulation (INR, etc.) to be sure it is sufficiently low during those times. Of course, before and after those times the main concern would be clotting events due to sub-therapeutic ACT. Every reference states that this is complicated and requires understanding on the part of the team administering the epidural.

Whatever you do, don't do it on your own. As everyone else has said, do involve your medical team. You might want to print off Al's bridging regimen and see if they feel it applies in your situation. (http://www.warfarinfo.com/bridgetherapy.htm) Here's another reference for your info: www.asra.com/Consensus_Conferences/Horlocker3.pdf

All the best to you!

[RandyL]

Looks like Al's bridge recipe is 1mg of lovenox every 12 hours. My shots are 60 mg which I took once a day after my surgery waiting for my coumadin to become theraputic. I guess I won't be bridgeing on 60mg before the procedure.

[tommy]

Randy,

You have several variables in this discussion. There are enough variables in the medicine and treatments, to add more unnecessarily. Here's how I sort them out. Back pain has got to be the pits - debilitating and demoralizing. Hang in there.

1. If you don't have confidence in your cardiologist, find another one. I don't mean to shop until you find one that you agree with, but you must get excellent care and have confidence of same.

2. IMO you should have professional assistance managing your Coumadin dose.

3. It is not acceptable to simply "go off" anticoagulants without a sound strategy. Every procedure has it's risks that have to be weighed against risk of bleeding and risk of stroke.

4. The doctors need to work together for bridging therapy. My cardio always calls the surgeon to negotiate the strategy. PS, my cardio always prevails.

5. Lovenox is dosed by body weight. I'm not sure where your 1 mg suggested dose came from. My dose is typically 90-100 mg.

6. Lovenox is administered every 12 hours because that's about how long it dissipates. If your procedure gets riskier because of bleeding, the docs may want you to stop Lovenox more than 12 hours prior to the procedure. See #4.

I wish you well. I'm concerned that your plan is not well thought out. Can you put this off until you get more/better help?

[RandyL]

I apologize if I came across wrong. I didnot consider bridgeing because neither the lab Doctors or my Cardio suggested it. Maybe I haven't chosen the right words to explain my situation, I am not trying to be a horses azz. The instructions I got were to stop coumadin 5 days before thew procedure and that was it. All I was trying to find out was how to start my coumadin back up or if I should take some Lovenox shots until I got theraputic on the coumadin. Now I don't know what I am doing to endanger myself other than the risk of being off the coumadin but I don't see anyway around this. Again I apologize if I have offended anyone.

[Lynlw]

I know that this doesn't help Randy, but since he first started asking about needing the epidural, and i could be off base here, but.something i have been thinking about alot (as a person w/ a really misserable back) is Maybe when trying to decide what kind of valve to get, somewhere in the discussions along w/ asking women in childbearing years, do you plan on having more children, is do you already have back problems?for most back problems i know it is a lifelong issue and when you are thinking about heart surgery, thinking about your back wouldn't cross my mind, if this hadn't been brought up. I'm certainly NOT saying everyone w/ back problems should get a tissue valve, but I think it should play some part in the thought process. I was wonderring if anyone elsehad thoughts about this, lyn

[RandyL]

Lynn, I hear what your saying. Sometimes I look back and think maybe I should of got the tissue valve especially since they seem to be lasting longer and longer. However the mechanical valve is still the best way to go. Coumadin is your friend not your enemy. I have no problem taking coumadin the rest of my life and it has not been a problem keeping the dosage in line so far. I have had a few back problems over the years, nothing a good chiropractor hasn't been able to fix. I didnot have back problems going into surgery, the last back problem was a good 10 years ago. When I woke from my second surgery my left thigh was completely numb and has been since January. It also pinches and burns occasionally throughout the day.After an XRAY and MRI I have a herniated disc that everyone thinks is causing the problem. My back doesn't even hurt. I have had 2 different chiropractors trying to help me with no success. At the suggestion of a orthepedic Doctor I took oral steroids which unfortunately did not work. They then suggested the epidural steroid injection. This is probably the only thing left to try before back surgery or enroll in pain management. I don't like the idea of either one. I still think the mechanical valve is the way to go, it just takes extra precautions to deal with when you have another illness that involves your blood.

[DrAllan]

This thread is the closest to “flaming” that I have seen on this site. I believe that the “1mg” statement is missing the fact that the dosage recommended by Al is “one milligram per kilogram of body weight”.

I have the feeling that many at this site think that “bridging” therapy is some sort of magic cure for being off of Coumadin but still protected by being anticoagulated. This is very far from the truth. A bridge is something that connects or allows passage from one place to another, many times across a river or some such impediment as a river of chasm. Because it takes several days for the effects of Coumadin to dissipate as well as several days for it to become effective when restarted, a heparin product such as Lovenox is used to bridge the time from the stopping point to the completion of surgery and then to the resumption of effective anticoagulation from Coumadin. WHAT IS MISSING in this discussion is that fact that from about 12-14 hours after Lovenox is stopped prior to the surgery until a few hours after it is restarted following surgery (usually 12-24 hours) that you are NOT anticoagulated and at risk of stroke. What the bridging therapy does is reduce this time at risk to a minimum compared to just stopping and restarting Coumadin.

[RandyL]

This thread is the closest to “flaming” that I have seen on this site. I believe that the “1mg” statement is missing the fact that the dosage recommended by Al is “one milligram per kilogram of body weight”.

I have the feeling that many at this site think that “bridging” therapy is some sort of magic cure for being off of Coumadin but still protected by being anticoagulated. This is very far from the truth. A bridge is something that connects or allows passage from one place to another, many times across a river or some such impediment as a river of chasm. Because it takes several days for the effects of Coumadin to dissipate as well as several days for it to become effective when restarted, a heparin product such as Lovenox is used to bridge the time from the stopping point to the completion of surgery and then to the resumption of effective anticoagulation from Coumadin. WHAT IS MISSING in this discussion is that fact that from about 12-14 hours after Lovenox is stopped prior to the surgery until a few hours after it is restarted following surgery (usually 12-24 hours) that you are NOT anticoagulated and at risk of stroke. What the bridging therapy does is reduce this time at risk to a minimum compared to just stopping and restarting Coumadin.

Thankyou, that makes a lot of sense. I will call my Cardiologist tomorrow to see if he wants me to do this. His instructions did not include this bridging procedure. It sounds like I would only be at risk for some hours versus days. Thanks again, I think I understand this now.

[RCB]

With all due respect Dr.
This thread is the closest to “flaming” that I have seen on this site.
If this is your experience, you haven't read much of this site. Check out some of the threads on Valve and Small Talk forums that make this seem polar by comparison.:D



I have the feeling that many at this site think that “bridging” therapy is some sort of magic cure for being off of Coumadin but still protected by being anticoagulated. This is very far from the truth. ............. WHAT IS MISSING in this discussion is that fact that from about 12-14 hours after Lovenox is stopped prior to the surgery until a few hours after it is restarted following surgery (usually 12-24 hours) that you are NOT anticoagulated and at risk of stroke. What the bridging therapy does is reduce this time at risk to a minimum compared to just stopping and restarting Coumadin.
Reducing the time is about as close to "magic" as we can expect. No ACT is perfect. People have strokes when fully in their INR range. Tissue valves can be a source of strokes, specially during the end of their life. All one does with bridge therapy is attempt to lower the risk. "lower the risk" is the goal in most medical procedures. In 46 years of ACT, I have had one major stroke(being off warfarin) and no bleeds. Any Dr. who ask me to go off warfarin without some kind of bridge therapy, simply doesn't get my business. Strokes
can make HVR look like a cake walk.

[Nancy]

I just want to put in my two cents. Joe has been on anticoagulant therapy for 28 years. It is ABSOLUTELY NOTHING to fool around with. It has to be taken care of with as much thoughtfulness as humanly possible.

During those 28 years, Joe has been off Coumadin and on to bridging therapy numerous times. Minimizing his risks is of utmost importance. So, he will NEVER go without bridging therapy. He cannot take Lovenox or Fragmin due to kidney issues. So he has to go into the hospital several days prior to any procedures, for IV Heparin and then on the back side, he has to stay several days on Heparin until his INR gets into therapeutic range.

During those years he has also had numerous TIAs, splenic infarctions, and a retinal artery occlusion causing blindness in his left eye. Some of these were when he was within his INR range, some were not. They were all clots coming off his valves. He also has afib from time to time, and it is also possible that the afib could have caused some of these clots.

Joe also has bleeding issues in his GI tract. So he has a double edged sword. His INR range has to be as low as possible to keep him from bleeding to death, but high enough to keep clots from forming. It's a very narrow INR range.

So what RCB says is very true. The only thing that can be done is to try to minimize risk. It is very serious business and it has to be done right.

[ALCapshaw2]

This thread is the closest to “flaming” that I have seen on this site. I believe that the “1mg” statement is missing the fact that the dosage recommended by Al is “one milligram per kilogram of body weight”.

I have the feeling that many at this site think that “bridging” therapy is some sort of magic cure for being off of Coumadin but still protected by being anticoagulated. This is very far from the truth. A bridge is something that connects or allows passage from one place to another, many times across a river or some such impediment as a river of chasm. Because it takes several days for the effects of Coumadin to dissipate as well as several days for it to become effective when restarted, a heparin product such as Lovenox is used to bridge the time from the stopping point to the completion of surgery and then to the resumption of effective anticoagulation from Coumadin. WHAT IS MISSING in this discussion is that fact that from about 12-14 hours after Lovenox is stopped prior to the surgery until a few hours after it is restarted following surgery (usually 12-24 hours) that you are NOT anticoagulated and at risk of stroke. What the bridging therapy does is reduce this time at risk to a minimum compared to just stopping and restarting Coumadin.

I'm not sure what you are refering to in regard to your comment about "flaming". If that was construed from any of my comments, please know that was NOT my intent.

When I had an upper endoscopy and colonoscopy, my GI Doc INSISTED that I go off Coumadin. My Cardiologist and Coumadin Clinic recommended Lovenox Bridging which was managed by the Coumadin Clinic to MINIMIZE my risk / exposure. I was fully aware that I was at risk for about 24 hours (but NOT 5 days). We are in agreement on this issue, I just didn't address it in my previous comments.

My understanding of Lovenox dosing also agrees with your statement, 1 mg of Lovenox per Kilogram of body weight. Note that 1 kg = 2.2 lbs. so a 220 lb. person would take 100 mg of Lovenox every 12 hours. I was told to discontine the Lovenox 24 hours before my procedure and resume the night after the procedure, along with a tapered 'loading' schedule of Coumadin.

My comment about letting the experts manage the Coumadin and Lovenox Bridging has both a medical and legal basis. I would assume that any patient who does NOT follow his Doctor's orders absolves that Doctor from any responsibility if something goes wrong and the patient would be considered to be "NON-Compliant".

FWIW, I also agree with the comments from Tommy.

Randy, if you do not have confidence in your Cardiologist, you need to find one who inspires confidence. I also wonder who is overseeing your Coumadin Management.

Many of us have found that dedicated Coumadin Clinics seem to do this best and Good Cardiologists often refer their patients to such clinics. This relieves the Cardio from what I suspect he would consider to be a routine maintenance issue while ensuring proper and knowledgable care, i.e., a WIN-WIN situation for patient and physician.

Bottom Line:

Do NOT self dose Lovenox for this procedure.
Get proper medical management and authorization
that is agreed to by a Cardiologist and the Surgeon.

'AL Capshaw'

[PJmomrunner]

There was a post by a well-intentioned poster that could be construed as rather inflammatory. It was removed.

[Nancy]

Agree wholeheartedly with Al Capshaw regarding not dosing yourself with Lovenox or Fragmin. This is too tricky a thing to try to do yourself. No one wants to end up with a stroke due to poor management.

[ccrawford]

Only a couple of things I might add. First is that it doesn't hurt to know how to compute the dose for lovenox just to check your doc's computations. I had a dvt last year and the ER doc wrote the prescription wrong, giving me twice the dosage needed. If I hadn't checked it, I would have been in trouble. Secondly, check out the thread called "questions for Al" that deals with an expression of risk from being off Coumidin. The risk isn't as high I as first thought, but still enough to try to always opt for bridge therapy.

[geebee]

There was a post by a well-intentioned poster that could be construed as rather inflammatory. It was removed.
Thanks PJ as I was also wondering what Dr. Allan meant by "flaming". I must have missed that post.

[bvdr]

I just wanted to add that the morning of my cervical epidural the doc had blood drawn to document that my INR was at or below 1.

I think I was off coumadin for 5 days before the procedure. My INR was out of range and quite high when I went off and I was pleased about that since it reduced the time I was below my range. If there is a next time my PCP said he wants me on IV heparin and I agree. I didn't like how exposed I felt.

[RandyL]

Well I hate to write this but I will. I made the appt with my Cardiologist as recommended by most here and saw him today.he did a 3 month check-up, the usual, listened to my heart and did an EKG. Everything fine. I asked him about my procedure, coumadin, lovenox bridging, and so on. His answer was for me to only stay off coumadin as little time was necessary. When I started asking him about bridging on Lovenox he said let me call the Doctor at the lab and see what he says. I sat there and waited for him to call and consult with the lab Doc. He came back to me and said I had to go off the coumadin 5 days before the procedure and there would be no Lovenox bridge. I asked him what about after the procedure, do I start coumadin right away, what should my dose be,what about Lovenox bridge while my coumadin was working its way toward therapeutic? His answer was ask the Doctor at the lab how to proceed after the procedure. As you can see I am not getting much help from my Cardio but I guess I will take his advice and not bridge with Lovenox since I don't know how to do this on my own. When I go for the procedure I will ask the lab Doctor how to continue my coumadin like my Cardiologist told me to.

[Christine]

I'm still not crazy about the 5 days off coumadin - if I read it correctly, without any heperin or otherwise? when I had scheduled a colonoscopy few years back.. they had me go off for 3 or 4 days, but I also was on heperin shots twice a day leading up to the procedure.. ended up not having it as I landed in the ER the day before for a totally unrelated issue other then low INR. - allergic reaction to an iron infusion I had that day..

my INR was around a 1 then, which is where it needed to be for the procedure, but until the nite before, I was at least bridging with heperin .. once back on coumadin.. i didn't take the shots, just a dose and a half to start and went from there..

good luck

Chris

[Granbonny]

I just wanted to say.. I'm sure you will be fine..Try not to worry about being off coumadin ..Have your procedure monday..and then your coumadin again.... I'm sure the doctor doing the procedure will tell you what mg. to start back on......May take a few days to get back in range. Just watch the Vit.K intake.....Like I said, I'm sure you will be fine and hope this helps with your back...Bonnie

[Ross]

Ross,

I tried to respond to Randy L's last post regarding the response from his cardio but AOL kicked me off VR.com with a note that I needed to upgrade my Browser. (I know, but the dialup download is almost 2 hours and yada yada yada).and that my browser was not capable of reading the content of that site.

Could you post the following to Randy L for me?
IMHO, his Cardio is putting him at HIGH RISK with the recommendations outlined by Randy

----------------------

WOW Randy, no wonder you have no confidence in your cardiologist!

Please tell us, WHO is managing your Coumadin and monitoring your INR?

I can't help but get the impression your current Cardiologist is not comfortable managing Coumadin OR Lovenox and does not want to be responsible for the outcome, hence his suggestion that the (non-cardiac) Surgeon manage your Coumadin for the procedure.

If I were in your place, I would find ANOTHER Cardiologist ASAP, one who understands how to manage Coumadin and Bridging Therapy and who understands (and appreciates) the RISK of not being anticoagulated for several days.

'AL Capshaw'

[RandyL]

Thanks Ross

And Thanks again for the millionth time AL.

To answer your question I am monitoring my own INR based on your chart you sent me. I have a home test and it seems to be working great. I have been in my range for 6 weeks now and have not had to change my dose at all.I test every week at the same time.

I will have to stick with what the Cardio and Lab Doc has advised for now. I would however like to know what your advice is after the procedure since my Cardio just said to ask the lab Doc. I have checked into getting a new Cardio that has a coumadin clinic in his group. But for now would like your opinion if you don't mind.
Thanks

[DrAllan]

Randy,

It is obvious to me that your cardio neither is knowledgeable about Coumadin or interested in learning or treating your properly. Now what does it mean about “calling the lab doctor?” Diagnostic laboratories are run by pathologists, who may very well be very knowledgeable about the tests, the indications and what the results mean. They may be very aware of what confounds the testing. They are not very likely to be knowledgeable about treatment protocols except to the extent that they see abnormal lab results and may inquire or be informed as to the factors leading up to these abnormalities. Regardless, this was an informal consultation between physicians; you are not a patient of the “lab doctor”. Your chances of finding this person and talking to him are practically zero. If anything your cardio, in his ignorance of anticoagulation, should have been seeking the advice of a hematologist (doctor who specializes in diseases of the blood system), or a certified coagulation expert such as our own “Al” on this site. You have been denied proper preoperative e advice and care and have no one giving you postoperative care. Except for you self-dosing your own Coumadin trying to use your remaining 5 Lovenox is inadequate for both the preoperative and postoperative time periods. The fact that you have 5 syringes of Lovenox left over from your surgery is tempting to use but dangerous without supervision.

My advice at this point is to print our all of the responses to this thread, put them in an envelope for your next-of-kin or responsible care giver to use to sue the incompetents caring for you if disaster strikes.

This answer is not intended as and does not substitute for medical advice - the information presented is for patient education only. Please see your personal physician for further evaluation of your individual case.

[RandyL]

Dr. Allen,

I appreciate your direct approach. I have a call into my Surgeon to get his opinion and direction. I will most definately change Cardiologists. If my surgeon says to go ahead with the procedure without bridging then that is what I will do. If he says to definately bridge then I will reschedule my procedure and seek out a new Cardiologist. Thank you for taking the time to answer my questions. BTW the lab Doctor is a neuroradiologist.

[ALCapshaw2]

Dr. Allen,

I appreciate your direct approach. I have a call into my Surgeon to get his opinion and direction. I will most definately change Cardiologists. If my surgeon says to go ahead with the procedure without bridging then that is what I will do. If he says to definately bridge then I will reschedule my procedure and seek out a new Cardiologist. Thank you for taking the time to answer my questions. BTW the lab Doctor is a neuroradiologist.

Randy,

I can't help but be VERY concerned about proceeding without consulting *someone* who understands and appreciates the SIGNIFICANT RISK of STROKE when you are NOT anticoagulated. Most NON-Cardiac Doctors / Surgeons are more concerned about the Risk of Bleeding than the very significant risk of STROKE, hence their advice to go OFF Coumadin for 5 days. As far as they are concerned, if you have a STROKE, that is YOUR problem for which you will consult someone ELSE.

Taking this VERY BAD advice and "throwing your fate to the wind" scares the H*** out of me. Since my GI Doc refused to do my Upper Endoscopy and Colonoscopy while anti-coagulated, my Cardiologist recommended Bridging Therapy to be administered and monitored by the Hospital's Coumadin Clinic CRNP. The GI Doc concurred with this approach and all went well.

Are you familiar with the cases on VR.com where one or two patients suffered PERMANENTLY DISABLING STROKES while OFF their Coumadin for routine Colonoscopies? I've forgotten their name(s) but I'm sure you can find the posts and followup, including a copy of the LAWSUIT filed against one of the Doctors for negligence.

BTW, AL Lodwick is the our resident Coumadin Clinic Director (from Colorado).

'AL Capshaw' (just another AVR patient and mechanical valve recipient who takes Coumadin)

[ALCapshaw2]

Thanks Ross

And Thanks again for the millionth time AL.

To answer your question I am monitoring my own INR based on your chart you sent me. I have a home test and it seems to be working great. I have been in my range for 6 weeks now and have not had to change my dose at all.I test every week at the same time.

I will have to stick with what the Cardio and Lab Doc has advised for now. I would however like to know what your advice is after the procedure since my Cardio just said to ask the lab Doc. I have checked into getting a new Cardio that has a coumadin clinic in his group. But for now would like your opinion if you don't mind.
Thanks

MOST people who home test have *some* Doctor or Clinic that monitors their INR (you call in the measurement from your home test machine and they tell you if you should make any changes, or at least record your input for their records).

Do you have a Primary Care Physician?

If so, have you advised your PCP of the recommendations you have received from your Cardiologist and Surgeon?

It is the job of the PCP to look out for YOUR best interests and coordinate all your 'other' doctors / specialists to be sure everyone is on the same page. Perhaps your PCP can find you a more supportive Cardiologist who will take a more proactive interest in your Coumadin / INR monitoring and management.

If I were in your shoes, I'd postpone the procedure until you get a second opinion, hopefully from someone who understands the benefit of Bridging Therapy and how to bring your INR back following the procedure. You should NOT be doing that on your own.

'AL Capshaw' (the AVR patient, NOT the Coumadin Clinic Director who is Al Lodwick)

[Georgia]

I've been waiting to see what others have said.

Now, my two cents:

When I had a herniated disc the excellent back surgeon I saw said I'd have to be in a wheelchair before he'd do an epidural b/c of the risk of stroke from going off coumadin. I was sent to pt and eventually the disc healed itself.

I KNOW how bad the pain is. It nearly drove me crazy. But I don't think the risk of being off coumadin without bridging therapy is worth the relief you may get from the epidural. I'm with Al; I'd delay the procedure.

But whatever, best of luck and hope this gets straightened out.

[allodwick]

When I am consulted about restarting warfarin, I say that when the surgeon thinks that there is little risk of bleeding, start warfarin that night at the same dose as prior to surgery. Since it takes about 3 days for it to start building back up, it poses little risk of causing bleeding. Due to diet and exercise concerns the dose of warfarin may be less than it was before surgery, but using the same dose gives a good starting point.

[Consuela]

I, too, have been told to go off coumandin while I have a biopsy of two cysts in my thyroid. I hesitate to do this, so I called my surgeon and asked the best way to go about it. My PCP first said go off coumandin for a week and then said make it three days prior and then have the procedure and then wait 24 hours and then resume. It sounded like he wasn't sure and then proceeded to tell me that it was dangerous. I walked out of his office more confused than ever.
I spoke to the surgeon who gave me my St. Jude Mechanical Valve on December 14th of last year, and he said that the best way to do this is to have an IV drip of Heparin and the procedure done in the hospital.
It seems that the doctors handle this like a hot potato. No one wants to get involved.

[allodwick]

One of the big reasons that doctors are confused is that there are no good studies that provide guidance on what to do. Mechanical valves are not hot political topics like AIDs so there is little federal funding. Heparin is generic and dirt cheap so no company is going to profit from such a study. The result is that nobody is sure of what to do. If you posted a poll on here and asked how many have mechanical valves and had a thyroid biopsy there would be very few responders. So it is unlikely that even one doctor has ever handled two cases. While "in my experience" is the lowest grade of proof, it is unlikely that you can find a doctor who even can say that. This is why this forum provides such valuable information. If anyone else on here has ever had it done, you can be sure that you will get a response.

[Consuela]

I got the answer I want. [I] asked the surgeon that gave me my mechanical heart valve and he told me that I would go off the coumandin and go to the hospital for the heparin drip and they would do the biopsy of the thyroid cysts and then I would resume the coumandin the following day. He also said that Lovenox was NOT FDA approved.

[allodwick]

Neither is heparin.

[RandyL]

Well I hate to write this but I will. I made the appt with my Cardiologist as recommended by most here and saw him today.he did a 3 month check-up, the usual, listened to my heart and did an EKG. Everything fine. I asked him about my procedure, coumadin, lovenox bridging, and so on. His answer was for me to only stay off coumadin as little time was necessary. When I started asking him about bridging on Lovenox he said let me call the Doctor at the lab and see what he says. I sat there and waited for him to call and consult with the lab Doc. He came back to me and said I had to go off the coumadin 5 days before the procedure and there would be no Lovenox bridge. I asked him what about after the procedure, do I start coumadin right away, what should my dose be,what about Lovenox bridge while my coumadin was working its way toward therapeutic? His answer was ask the Doctor at the lab how to proceed after the procedure. As you can see I am not getting much help from my Cardio but I guess I will take his advice and not bridge with Lovenox since I don't know how to do this on my own. When I go for the procedure I will ask the lab Doctor how to continue my coumadin like my Cardiologist told me to.

Well, I went for my epidural today didn't hurt to much. I asked the lab Doc how I should resume my coumadin. His answer was to check with my Cardiologist. Boy, passing the buck sure is common when it comes to this topic. My heart surgeon was the only one to step up to the plate and tell me what to do without heming and hawing. I started my coumadin as soon as I got home and I will taking my Lovenox shots starting 24 hours after the procedure twice/day(60mg) until I test therapeutic with my coumadin. It was an eerie feeling being off the coumadin for 5 days but they didn't even want me to take an aspirin. Anyways thats the good news. The bad news is I have to wait 2 weeks and do the whole process over again. That really sucks.
will prolly take me a week to get therapeutic and then I have to stop again. Oh well what can I do? That tissue valve is looking better and better all the time. Too late now.:)

[ALCapshaw2]

Glad you made it through Randy.

I'd call your Surgeon back, tell him they want to do it again in two weeks, and ask HIM if he would recommend (or at least support) Bridge Therapy BEFORE and AFTER the next procedure.

Then I would ask the Surgeon for a recommendation for a Good CARDIOLOGIST, citing the complete lack of support your current Cardiologist gave you for this procedure.

Based on your 60 mg of Lovenox, at 1mg per kilogram (=2.2 lbs) I calculate that your weight must be 132 lbs (or close to that). Is that correct?

YEP, everytime one needs an invasive procedure, the idea of a tissue valve is VERY APPEALING :D

'AL Capshaw' (AVR with St. Jude Mechanical Valve)