Stopping coumadin for Vitrectomy

[brendamarlene]

I am scheduled to have a vitrectomy (retinal eye surgery for a macular hole), and the surgeon would prefer me to stop my coumadin. My cardiologist suggests stopping coumadin 2 days before the surgery, and after the surgery, taking a double dose. Does this sound right?

I currently take 7.5 mg/day. After reviewing many of the bridging therapy posts here, I think that because I have a mechanical aortic valve, I am at a low risk for stroke (as compared with mitral valve). Is that true?

Thanks for any advice and thoughts.

 

[Guest]

I don't know that any guidelines have been developed for this procedure.

 

[ALCapshaw2]

I have been told to use LOVENOX Bridging Therapy (do a VR.com SEARCH to find protocols) for my invasive procedures. The CRNP at my Coumadin Clinic developed the dosing and timing schedule for BEFORE and AFTER.

'AL Capshaw'

 

[brendamarlene]

Risk like CATARACT surgery

Risk like CATARACT surgery

Evidently, the risk is similar to that in cataract surgery.

My main question is---is it OK to stop the coumadin for 2 days---and not use Lovenox---and then take the double dose after surgery.

Also, am I considered in the "low risk for stroke" group?

 

[Sierra Bob]

Vitrectomy

Vitrectomy

On 12/30/05 I became blind in my right eye in a period of a little more than an hour due to a Cenral Retina Artery Occulsion. I then developed Neovascular Glaucoma which caused extreme pressure and pain in my eye. I had a Baer Implant and a vitrectomy in April. I did not go off of warfarin for the surgery and had severe bleeding in the eye which caused a partial retina detachment. I suggest you go on a Lovenox bridge.

 

[warrenr]

eye surgery

eye surgery

This link might give you a look at both sides. It is a discussion between physicians about stopping of coumadin for this procedure. One of the physians even mentions that he had a patient that had a stroke when there coumadin was stopped.

http://commonspot.aao.org/forums_final/Diabetic_retinopathy/index.cfm?frmid=4&tpcid=27

It sounds like your cardio is talking about a monitored reduction to get you in the low end of your therapeutic range with a 2 day hold. If you decide on this route make sure your INR is checked just before you stop. If it is 2.0 or below make sure you talk to your cardio and surgeon. They may not want you to stop your coumadin if it is allready at the lower end. Also make sure you let the cardio and surgeon know of your concerns about stopping coumadin and make sure they document your discussion. The stopping of your coumadin and or bridging should be a decision between the three of you not just them.

 

[brendamarlene]

Use Lovenox?

Use Lovenox?

Evidently, the surgeon would like an INR of about 1.1-1.5 for the surgery. He said they will check my INR that morning of the surgery at the hospital.

I am going to see my cardiologist tomorrow. I will discuss Lovenox with him. Are there any reasons NOT to use lovenox for those 2 days while I stop the coumadin?

I have been going to the clinic to have my coumadin checked every two weeks. After this eye surgery, I will be stuck at home with my head in a down position, so I will not be able to get to the clinic so easily.

Is there any way to get a home monitoring machine ASAP? So I can check it more frequently right after the surgery.

 

[brendamarlene]

I wish I had an expert with whom to consult----seems that is you guys, mostly. Well, my surgery is this Monday, and I am discontinuring the coumadin until then. My coumadin was down to 2.0 on Friday. This is scary!

 

[doyo]

Double Dose may not be a good idea

Double Dose may not be a good idea

If I did a two-day hold with no bridging, I wouldn't be therapeutic (assuming I wasn't too high to start with.) You might ask what INR the eye surgeon is shooting for, then you will have a better idea how long to hold your dose, bridging or no bridging. Also, I don't think the "double dose" plan when you restart the coumadin brings your INR back up any faster -- does it, Al?

Al can tell you for sure.
But what I read is "doubling up the dose" does not really brings INR up any faster. In fact it can do a harm, either bleeding or paradoxically, clotting due to hypercoagulable state. See article in the link below. I copied and pasted the section. This section is about 1/4 way down the article.

http://www.aafp.org/afp/990201ap/635.html

"Loading doses of warfarin (i.e., 10 mg or more per day) may increase the patient's risk of bleeding episodes early in therapy by eliminating or severely reducing the production of functional factor VII. The administration of loading doses is a possible source of prolonged hospitalization secondary to dramatic rises in INR that necessitate increased monitoring. Administration of loading doses has also been hypothesized to potentiate a hypercoagulable state because of severe depletion of protein C. The practice of using loading doses should be abandoned because it has no effect on the inhibition of thrombosis.4[corrected]

A potential paradoxic consequence of loading doses is the development of a hypercoagulable state because of a precipitous reduction in the concentration of protein C (approximate half-life of eight hours) during the first 36 hours of warfarin therapy.12 Thus, loading doses theoretically may cause clot formation and/or expansion by limiting the production of proteins C and S, which have shorter half-lives than prothrombin. Consequently, the concurrent use of heparin is extremely important. "

EJ