Stopping Coumadin For Oral Surgery

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T

tcerame

Hello everyone!
have not posted for along time but life has gotten back to the crazy, hectic, stressfull way before my AVR so I guess that means I 've survived the worst and moved along. Now to my reason for posting, I just wanted to get other valver's experiences on stopping coumadin before surgery. I am scheduled to have a wisdom tooth cut out next week and after my cardiologist talked with the oral surgeon they want me to completely stop taking my coumadin for 4 days before the surgery then take 10 mg that eveing of the surgery and 7mgs for the next 3 days then test. By the way I do home testing and they want to get my inr down to around 2.0 so I have to test the day my surgery is scheduled. What does everyone think, I'm not trying to second guess the doctors but I have concerns getting off that long and trying to get my level back after stopping. Thanks for everyones help and support in the past.

Tom
 
The only concession I made recently for an extraction was to reduce my INR to the lower end of my range. I am not sure it made that much difference but I seemed to have less "seepage" bleeding after the extraction than the dentist thought I would.

If your range is 2.0-3.0, taking your INR down to 2.0 should not hurt but I would definitely not take it any lower since the "accepted" variance could even mean you would be less than 2.0.

The lower end of my range is 3.0 and I was fine so I think you could easily be at 2.5 without any problems.
 
I would check this out:

I would check this out:

I just had a tooth extracted, and my cardio had previously said he takes people off warfarin-so I knew he was out of date. I did a lot of research and in my opinion, the latest & best thinking is that an extraction can be done with an IRN of 3 or less. I started calling oral surgeons, and all of the old guys wanted me off warfarin. I finally got to a guy who did his residency in the last 5 years. He said the latest research is to do an extraction as long as the INR is 3 or below. He also said they have a lot of new resources for stopping bleeding, and didn't think it would be a problem. In my case he was definitely right. It would be hard to talk me into going off warfarin for as long as your guy is saying, but-I am not a doctor.

I would recommend using an oral-surgeon, and I might try to find a Dr. that did their residency in the last 5 years.
 
MY first choice would be to find an Oral Surgeon with EXPERIENCE (and a good track record) doing extractions while still anti-coagulated at the low end of your recommended range.

IF you want to stay with your current guy, I would strongly suggest you contact your Anti-Coagulation Manager about BRIDGING therapy using either LOVENOX which you can self inject or a Heparin Drip which requires a hospital stay.

BOTH of the above mentioned Bridging Therapies are short acting and will provide protection until 12 to 24 hours (depending on the recommended procedure) before your surgery and can be resumed 12 to 24 hours following surgery. The procedure is to continue Bridging until your INR is back into range. This way your 'down time' can be as short as 24 hours or up to 48 hours, depending on the surgeon's assessment of the risk of bleeding.

FWIW, I have undergone 2 Bridging Protocols with NO problems (not counting the nasty bruise to my arm from a Blood Pressure Cuff that MAXed OUT due to improper placement while I was still anti-coagulated).

'AL Capshaw'
 
Is it possible to have a 2.0 INR after stopping coumadin for 4 days. It seems like it would be much lower than that after 4 days. I realize everyone is different but mine will drop like a rock after two days. Have you ever held it before for any reason. I have bridged multiple times for various surgeries and procedures and do feel that is a better way to go. Bringing it back up may be easier if you bridge.
Kathleen
 
Kathleen said:
Is it possible to have a 2.0 INR after stopping coumadin for 4 days. It seems like it would be much lower than that after 4 days. I realize everyone is different but mine will drop like a rock after two days. Have you ever held it before for any reason. I have bridged multiple times for various surgeries and procedures and do feel that is a better way to go. Bringing it back up may be easier if you bridge.
Kathleen
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Good point, Kathleen, and one I failed to comment on. When I took my INR down to 3.0, I only reduced my dose for the few days before the extraction. Since I home test (which luckily Tom does), I was able to check things every step of the way.

So, Tom, please do not stop for 4 days and then test. You could try what I did which was to reduce the daily dose by 20% or so starting one week before surgery. Continue to test every other day to see where you are. Any skipping regimen I will leave to others to comment on since I do not skip doses because I drop without control.
 
I hereby strongly object to stopping your warfarin for 4 days based on the following:

Simon Carruthers, Chairman BDA Formulary Committee, responds

"The issue of warfarin and primary care dental surgical procedures has been considered by the BDA's Dental Formulary Committee. It is the view of the Committee that the established guidance in this matter, as promulgated by the North West Medicines Information Centre in July 2001 and in the Dental Practitioners' Formulary, rests on a sound evidence base and should be adhered to by all dentists.

Patients who require dental surgical procedures in primary care and who have an INR below 3.0 should continue warfarin therapy without dose adjustment. In these circumstances, bleeding is easily treated with local measures. The risk of thromboembolism after withdrawal of warfarin therapy greatly outweighs the risk of bleeding."

Hence, as long as you INR isn't too high <=3, you can have whatever procedure you require. Prolonged bleeding is inconvenient, a stroke is devastating by possibly putting you in a wheel chair for life.
 
I think Al Lodwick would probably say that your dentist and your oral surgeon would rather you have a stroke than do a little more bleeding than usual.

With an AVR, if your INR range is between 2-3, it already appears that you meet the standards already.

If I stopped my Coumadin for 4 days, I'd probably be at an INR of 1 after 3. How much do you take? The more you take,the more quickly your INR will drop.

Dustin has an excellent post. Thanks Dustin!

If you are uncomfortable with not following the surgeon's instructions, and feel you most likely will do as they ask, do what Dennis did - look until you find a surgeon who is up to speed on protocol.
 
Update:

I called my ACT clinic to ask about protocols regarding primary care dental procedures and INR. It turns out that they will NOT change my dose for INR <= 4.0 ! They too said that meddling with my dose wasn't worth the risk of a stroke and its lifelong repercussions.
 
My inr range is 2.5-3.5. My most recent protime test was at 3.3 last monday. I agree that being completely off the coumadin for 4 days seems too long. My cardiologist and oral surgeon want me around 2.0 the day of surgery. I am going in today for a consult with the oral surgeon and I will be asking alot of questions. I will let you know how that goes. Thanks everyone for their input.

Tom
 
I have been exchanging e-mails with a woman who has a clotting disorder - not a valver. She had a stroke when she stopped warfarin to have a tooth pulled. Her dentist advised her to have all of the rest of her teeth pulled and implants put in. Because of the stroke the oral surgeon pulled 18 teeth while she was fully anticoagulated. She said the she did not bleed much at all.
 
I thought I might have to have oral surgery as well but I don't. Anyway, my Card said "Nope, no way your coming off Coumadin, the bleeding will stop". He convinced the Oral Surgeon as well to perform the surgery while on Coumadin.
 
Dennis,

Not much chance of a cardio (still in practice) moving to YOUR neighborhood.
 
Cleveland Clinic changed a pacemaker while on normal coumadin levels. They have been doing this for the past 5 years or more for patients with mechanical valves that require a pacemaker.

There is a MUCH higher chance of bleeding with the pacemaker replacement than oral surgery.
 
Patients with prosthetic heart valves requiring outpatient oral surgery are the only group of patients for whom LMWHs are not recommended.9 The more conventional heparin windows using traditional unfractionated heparin with inpatient protocols are advised for these patients.
Click to expand...
This is an excerpt fr om the article Betty posted. Has anyone had this done or heard that LMWH is a bad idea for prosthetic heart valve patients with oral surgery?
 
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