Lovenox and Coumadin concurrently

[Bryan B]

I did some searching but didn't find an answer to my question. When I was in the hospital in May they sent me home on Lovenox 80mg injections twice a day and Coumadin 7.5mg daily. Four days later my INR test resut was a 4.0. My range for a-flutter was 2-3. Ross even called it that I was over anti-coagulated. I could tell too because all of a sudden I had bruises showing up from Lovenox injections and blood draws that weren't there before (and these sticks were from the hospital stay). We stopped the injections and went to alternating 7.5mg one day and a half of a 7.5mg the next day (comes out ~5.6mg). The following week I my INR was 2.5 and it settled in the low 3's which was fine by me and my doctor.

This time they have sent me home on Lovenox 80mg twice a day, Coumadin 5mg daily, and they also put me on Synthroid 25mcg which will probably interact slightly with the Coumadin causing a slight rise in anticoagulation.

Now to my question. I'm seeing the bruising pattern showing up exactly like it did the first go round. Should I take it upon myself to cut back to one injection daily or just follow my doctor's orders and end up all bruised up and with a high 1st INR result. Last time I was starting anti-coagulation from scratch. This time they let it drop to 2 in order to do the ablation and I'm just guessing I was probably at 1.5 when they started the Lovenox and Coumadin back up. I really don't mind giving myself the injections (I've gotten pretty good at it...better than the nurses) but I hate all of the brusing. I honestly feel like I'm already between 2-3 and that 5mg is going to be the perfect dose for me. If I keep up with the Lovenox my INR will be high, they will stop the injections, and possibly mess with my Coumadin dose which will have me bouncing around.

The ablation was successful so this time round the Coumadin is more precautionary where last time they found a clot in my heart and wanted that sucker dissolved asap. My cardio said that she will probably take me off the Coumadin when I see her on 7/20, which is only 2 weeks and 2 days from now.

Any thoughts would be appreciated. I know it will be a slow weekend for responses (I'm about to go play golf myself). I'm more curious than anything about how someone experienced in anti-coagulation would handle this situation. Personally I'm going to cut down to 1 Lovenox injection daily as well as my 5mg of Coumadin daily. I really don't see how in the world I could be below 2 with that unless I sit down and eat a big bowl of collards every day until my INR draw on Tuesday (and trust me that aint gonna happen).

I've already given myself my morning injection so if the consensus is to stay the course with what the doctor ordered I can still give myself my night time dose and I will be on schedule.

 

[Ross]

Continue both injections or at least until your INR is tested. I'd hate to see you develop and throw a clot in the meantime. You may well be over range already with the INR, but I'll take the bruising over a stroke anytime until I'm sure it's safe to stop. You might call and tell them about the bruising and see if they can bump the INR draw up.

If Synthroid is anything like my Fenofibrate, you may well still be taking too much Coumadin. I went from 42.5mg a week to 30mg a week after starting it. That's a big cut.

WARFARIN SODIUM (in Coumadin Tablets) may interact with LEVOTHYROXINE (in Synthroid Tablets)

Blood clotting normally occurs in response to a cut or other types of injuries to protect the body from excessive bleeding. Many substances are involved in the clotting process including various chemicals that are produced in the body like vitamin K.. Warfarin is generally used to prevent your blood from "coagulating" or forming blood clots. Although levothyroxine does not appear to directly interact with warfarin, it may increase the breakdown of vitamin K-dependent clotting factors and make your blood much less likely to clot. When levothyroxine and warfarin are used at the same time, the anticoagulant effect of warfarin may be increased and this may increase the risk of excessive bleeding. If these drugs are taken together, your doctor may want to monitor you closely for signs of bleeding (bruising, nose bleeds, ect). Blood tests can be used to make sure that you are getting the right amount of warfarin. If you are experiencing problems, it may be necessary to adjust the dose of warfarin.Ask your healthcare provider about these drugs and this potential interaction as soon as possible.

This interaction is well-documented and is considered major in severity.

 

[ALCapshaw2]

Brian,

My advise is NOT to skip the second Lovenox Injection. If you don't already know, Lovenox has a Short Half Life and is pretty well GONE from your system after 12 hours. NOT a good thing if you DO NOT KNOW your INR.

You probably already know that there is NO set Standard for Bridging.
I asked 3 Surgeons about their protocol and got 3 different answers.

1- NO Bridging
2- Bridging Before but NOT After
3- Bridging Before and After with an eye to balancing the Bleeding Risk vs. the Risk of Stroke After the procedure, i.e. adjusting the return time to Lovenox by a few hours to 24 hours to 48 hours. depending on the Risk Assessment..

I suppose you could "go with your gut" but I would NOT make any changes without an INR Test so that you KNOW where you stand.

'AL Capshaw'

 

[Bryan B]

Thanks guys. I pretty much knew that was the answer but I wanted to run it by you since I'm a anti-coagulation newbie. My gut tells me I'm already between 2-3 (if not higher) but since I can't test myself it's just a guess. And like Ross said it's better to look like a VERY RIPE banana than to throw a clot and have it end up somewhere bad. Speaking of "gut"...it's about that time to pinch a love handle and "stick a fork in it".

And Al it didn't dawn on me that Lovenox had that short of a half life...which it should have since I'm a pharmacy guy and it is dosed every 12 hours.

BTW...more bruising today...ugly "out of the blue" bruising from where they poked and prodded me while in the hospital. I really do look like a over ripe banana right now...lol.

 

[Marty]

Bryan, the half-life of Lovenox is about 2.5 hours. The half-life of warfarin is 2.5 days

 

[Bryan B]

Thanks for the info Marty...that's pretty quick. I had my INR blood draw today with my favorite phlebotomist...even got a hug from her today ;-)...so I should get a call with the results tomorrow. I'm guessing something in the mid 3's. I've been between 2.5-4.0 with every outpatient test I've had so far (4.0, 2.5, 3.4, 3.8).

 

[ALCapshaw2]

Call Back Tomorrow ? ? ?

GOOD GRIEF !!

At my Coumadin Clinic, Finger Stick Results are read within several minutes.
Even the Lab Draws come back to the Clinic in less than 2 Hours and my CRNP calls me at her first opportunity!
(the sample tubes are sent down street to the Main Hospital Lab in Pneumatic Vacuum Tubes,
similar to those found at drive up windows at banks)

'AL Capshaw'

 

[Bryan B]

Call Back Tomorrow ? ? ?

GOOD GRIEF !!

At my Coumadin Clinic, Finger Stick Results are read within several minutes.
Even the Lab Draws come back to the Clinic in less than 2 Hours and my CRNP calls me at her first opportunity!
(the sample tubes are sent down street to the Main Hospital Lab in Pneumatic Vacuum Tubes,
similar to those found at drive up windows at banks)

'AL Capshaw'

Al,

Since I'm only on Coumadin temporarily (and there is not a Coumadin Clinic nearby) I have my INR checked at the Duke Health Clinic on Tuesdays when they see ACHD patients. They don't have a lab onsite and send their blood samples to the main hospital which is about 10 miles away. Also since I can go anytime and the traffic is terrible in the morning I usually go in the early afternoon which would give them less time to read the test and get back to me. I have no problem waiting until the next day to get the results. My cardiology group's CRNP calls me the next morning, gives me the results, and lets me know if I need to make any changes. She called this morning and I was at 2.8 which was fine (although my prediction of mid 3's was off a little bit. I will probably be taken off of Coumadin in 2 weeks anyway. They have me on it now as a precautionary measure after my ablation until they feel there is no longer a chance of a clot forming either because of the ablation or the insertion for the catheter. The insertion site has healed up nicely and I no longer have any soreness and my heart rate is now spot on with a resting rate in the mid 70's consistently.