INR and injections

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bigsidster

bigsidster

Well-known member
Joined
Oct 19, 2010
Messages
184
Location
Tecumseh ,Ontario,Canada
Hello all

Have not been around for a while.Was on vacation and my INR went from 2.4 to 5.4 and my doctor is freaking out.The increase is due to not eating greens and salads while on vacation in Europe.Doctor had me stop coumadin for 2 days and then i could not get a hold of doctor so I resumed my regular dose of 5.5mg.In the meantime my INR dropped to 1.4.I am waiting for a call back from doc to see what dose she wants me on.I also have another problem.I am scheduled for a colonoscopy on Sept 30 and they want me to stop coumadin on sept 25 which is 5 days from now.I then take 3 injections on 27,28,29 of sept of INNOHEP and scope is sept 30.When do you start back on coumadin after this procedure?And at what dose.?
 
One of the two times that I know my INR went very high (blood in urine) occured while I was on vacation in Europe (Spain) in the early 1980s. I went off coumadin for a couple days, until I got home, tested INR and resumed normal dose (as I remember).

I am not sure that I would proceed with the colonscoopy until I got my INR stable.

Can't help with advice concerning going back to warfarin after this procedure. The idea of going off warfarin for several days is why I have not, and will not, get a colonoscopy and my PCP is OK with that since I am already in my later 70s.
 
Sid:
I had a colonoscopy 3 years ago and refused to go off warfarin. (I was stubborn about that.) So the GI doc said he'd do it if I got my INR down to 2.5. I home-test, so I was able to monitor it down to 2.5. Whaddyaknow? They never asked what my INR was the morning of the procedure!!!
We had a member here some years ago -- don't know if he's posted in a while -- who joined due to his dad having a mechanical mitral. His dad was about 65 and had a colonoscopy. Doctor had him go off warfarin and he had a stroke the afternoon or evening of the procedure. He had to go to a nursing home, died about 12-18 months later.
I related that story to my GI doc and reminded him that I take warfarin for a mechanical valve, not for a-fib. So he agreed to do it with an INR of 2.5.
 
I'd vote
a) Bridge with lovenox shots for the next couple days until you are back in range. 1.4 is too low. Bridging Dosage is 1 mg/kg of body weight, every 12 hours, until you are back above 2.0 (or ceasing about 16 hours prior to any surgery, if you are holding dosages for that reason).
b) resume your regular dose today, if not yesterday
c) delay the colonoscopy until you are stable and in range
d) only reduce to 2.5 for colonoscopy, as Marsha did, by reducing dosage for a few days
e) resume usual dose the night of the colonoscopy.
 
bigsidster said:
Hello all

Have not been around for a while.Was on vacation and my INR went from 2.4 to 5.4 and my doctor is freaking out.The increase is due to not eating greens and salads while on vacation in Europe.Doctor had me stop coumadin for 2 days and then i could not get a hold of doctor so I resumed my regular dose of 5.5mg.In the meantime my INR dropped to 1.4.I am waiting for a call back from doc to see what dose she wants me on.I also have another problem.I am scheduled for a colonoscopy on Sept 30 and they want me to stop coumadin on sept 25 which is 5 days from now.I then take 3 injections on 27,28,29 of sept of INNOHEP and scope is sept 30.When do you start back on coumadin after this procedure?And at what dose.?
Click to expand...

Holding 2 doses for your somewhat high INR was clearly overkill and dropped your INR like a rock.
A more prudent approach would be to hold one dose and re-test a few days later to see where you are at.

There are many docs who will do the colonoscopy with a lowered INR, see what you can find out about this, otherwise
we have several threads here on the topic.
Good Luck !!
 
I wouldn't go crazy about bridging with a 1.4 and an aortic valve. A few months ago, for some still unclear reason, I had a 1.1! I referred to a medical article, and the guidelines in effect at Duke Medical Center, and it said simply to increase dose for one day, and to increase weekly dose. I increased my dosage, retested every few days, and inside of a somewhat worrisome week, I was back in range. The risk of throwing a clot - even with a 1.4 - isn't as great as some here may have you believe - if you're slightly below range for a short amount of time. I did NOT bridge. Bridging would probably have been an overreaction.

If I had a procedure scheduled, I wouldn't want to muddy the information about my actual coagulation status by adding lovenox to my warfarin intake. I'd feel a lot safer if my coagulation status was ENTIRELY due to warfarin and lovenox had no impact on it whatsoever.

We've recently seen some threads here about problems with surgeries while bridging with Lovenox.

If I was having the colonoscopy (I've never had one, and without insurance probably won't ever have one), I'd do as Marsha suggests - get the INR to 2.5 and have the colonoscopy with an INR that is still in range, but not too big a risk for a moderately skilled doctor to do the colonoscopy without causing a lot of damage.
 
My doc said he would do the colonoscopy without stopping coumadin, but if he found any polyps, etc, he would not remove them. So I would have to have a second colonoscopy(after stopping coumadin and bridging with lovenox). So far, I've opted not to have one.
 
I may not be up to date on the latest procedures, but it was my understanding that for most polyps, they use a little looped wire that ensnares the polyp and kind of cuts it off. I thought that they also did cautery that stops the bleeding (but I may be entirely wrong). The thing with INRs is that the number relates to the time it would take to clot...with an INR of 2.5, it would take 2.5 times as long to clot as would an INR of 1.0. Thus, if a polyp would normally bleed for 3 or 4 seconds on a person with an INR of 1.0, the same polyp would take maybe 10 seconds to clot in a person with an INR of 2.5. It seems like the bleeding risk for small polyps shouldn't be that much worse for someone with an INR around 2 than it would be for someone who is not anticoagulated at all.

I'm wondering if your doctor may be getting a bit overly cautious. (You'll probably want to weigh the risks of NOT having a colonoscopy with the risk of actually having something to worry about -- family history, recent symptom changes, etc. should figure into the decision whether or not to scope).
 
I tested 5.4 on returning from vacation.Doc had me stop coumadin for 2 days and I resumed at 5.5mg and tested 1.4 .Doc then had me change dose to 4 mg for 2 days and tested 1.5 yesterday.I argued with doc and thought my dose should be 5.5mg but gave in and only took the 4mg.I eat a lot of greens and salad and they are not taking that into account.Today is Friday and my INR is 1.5 and I stop taking coumadin on Sunday for colonoscopy on the Sept 30.I have 3 injections of INNAHEP on tues,wed,and thur and resume coumadin Friday the 30.
 
There seems to be an ongoing assumption that bridging carries no risk. On other threads, we've seen how Lovenox was suspected as the cause of unnecessary bleeding post-op. Recent protocols don't recommend bridging for people with bicuspid mechanical valves who are more than 3 months post-op and with INRs below 2.0.
Clearly, the case with an upcoming colonoscopy is a somewhat different situation -- but I'm not entirely sure how important bridging too early will be to the procedure's outcome or risk of throwing a clot.

If it was me, I'd want to look at some of the negative effects of Lovenox before starting on it TOO early.
 
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