Lovenox tips and tricks?

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jeffp

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Hi all. MVR 18 years ago. Did (and doing) well and drifted away from the forum. Well, I’m back again.
I’m having a minor outpatient surgery, rather than a longer inpatient stay; we’re going to bridge with Lovenox. The directions are short and sweet, basically stop warfarin 5 days prior, when INR is 2.0, to start injections twice daily sub-Q and stop the day before surgery and start warfarin and injections the evening post surgery and continue until INR above 2.0. Doesn’t say where to inject, but I get it with the belly area. I’ve got enough fat there to have fun with. 😁
I’d like to keep the discomfort of the injection and bruising down as much as possible. Any tips that you’ve found to help? Warming the syringe? Ice to the area pre-injection? Massaging the belly after the shot? (My cat loves a belly rub.). Thanks.
 

Superman

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I just poked as needed. I’m amazed at the amount of thought some people put into what seems to be a very simple thing.

I didn’t have any crop top modeling gigs coming up and figured any minor bruising would be temporary. Just kidding. I didn’t even think that much about it.
 

jeffp

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Being a professional belly button model, I worry about the bruising (and the pain, and the burning, and the needles, and the other stuff I haven’t thought to worry about yet). Seriously though, like anything new and unkniwn (to me at least), the fear is probably worse than the reality. I picked up the dozen plus bag of these scary looking syringes today. Set them aside; out of sight, out of mind.
I’m doing a test for a few days get a feel for how quick my INR drops. Not all the way, but in the past 18 years, I’ve only missed one warfarin dose. (Yeah, just a bit OCD.). INR stays within range, with maybe a dozen over range occasions without any issues. I’m sure once this is behind me, I’ll look back at this thread and think “boy, what that a waste of worry energy”.
 

leadville

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@jeffp .

I found once the needle is in it's far less painful if you inject the content very slowly as opposed to just pressing it all in quickly ( big difference ) its more a sting than pain.

Don't inject the same site either , move around a little & you should 'not' rub the area after you've injected .
 

ChuckM

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@jeffp .

I found once the needle is in it's far less painful if you inject the content very slowly as opposed to just pressing it all in quickly ( big difference ) its more a sting than pain.

Don't inject the same site either , move around a little & you should 'not' rub the area after you've injected .
Following surgery I started receiving the Lovenox injections while still in recovery. Somewhere about the 2nd or third night removed from ICU, floor nurse with little to no experience comes in. Couldn't find the specific dosage size on the med cart so she figured it was fine to give me 2 shots of 1/2 the size. I think I got 4 shots that evening. Needless to say I had nice little purple spots all the way around my tummy.
 

Beach77

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I’ve bridged one time. Giving the first 2 shots were hard but it was easier after that. I watched a few youtube videos. Here's the one I saved for the next time I need to bridge.
There's bruising but it goes away. It wasn't bad at all. I ended up giving injections for 15 days, I think. My INR wouldn't go up even with upping the dose. That was more frustrating than the shots and colonoscopy. My thoughts it had to do with my thyroid.
 

Woodcutter

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Watching the video reminds me of a tip that will not pertain to all, but if it does can save some pain. When I bridged about a year ago, I gave myself the first injection as shown (per the included instructions) . .. . and it was quite painful (and ultimately left a bruise > 1 sq in). I then remembered what a nurse told/showed me when I received my first injections in the hospital almost a decade ago after MVR. Essentially she told me to NOT go straight in. Rather, try to go in a bit sideways or at an angle. The purpose is to inject into the fat. With the wrong combination of needle length and body fat (including how much you can pinch), I can share that it is indeed possible to inject into muscle and it is even less enjoyable!
 

jeffp

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“The purpose is to inject into the fat.”
Not something I expect to have a problem with. I’ve got enough fat for myself and 2 more guys, at least.

“and it was quite painful (and ultimately left a bruise > 1 sq in)”
Painful…I’d like to minimize that. 1sq in…that I could manage with. I’ve been imagining purple areas the size of a grapefruit.

I’ll be starting this bridging in a few weeks. First time’s alway the worst. Managed to avoid it all these years.
 

mina

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I took lovenox injections twice per day every day for the entirety of two pregnancies. I agree with the tips others have shared, and comment only to offer that even with a severely stretched side and having gone through months and months of injections, I only got really purple a couple of times at the end, usually when I inadvertently knicked a vein or had to inject into a bruised site for lack of other place to inject. This won't happen to you. :)
 

ChuckM

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I took lovenox injections twice per day every day for the entirety of two pregnancies. I agree with the tips others have shared, and comment only to offer that even with a severely stretched side and having gone through months and months of injections, I only got really purple a couple of times at the end, usually when I inadvertently knicked a vein or had to inject into a bruised site for lack of other place to inject. This won't happen to you. :)
You have the same name as my wife, very unique. :)
 

RobThatsMe

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Hi Everyone,
I have been watching this thread with interest. In the past I always had to bridge prior to a colonoscopy.
Now that I am 72, my doctor advised that I should have one last one, and That I will not be required to bridge.
He said I should maintain my normal inr range. This is new to me, as I always bridged for this.
Has anyone else, gone through this procedure without bridging? I have in OnX aortic valve, and planning to bring my INR down to 2 orr this procedure.
I have had a mechanical valve for almost 23 yrs. Although it was relaced once due to pannus inhibiting its performance.

Thanks for any feedback you can provide.

Rob
 

jeffp

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Now that I am 72, my doctor advised that I should have one last one, and That I will not be required to bridge.
He said I should maintain my normal inr range. This is new to me, as I always bridged for this.
Has anyone else, gone through this procedure without bridging? I have in OnX
I’ve had 2 colonoscopies since being on warfarin. For both I just was at the lower range of INR. No bridging, hence my questions and concerns about something new to me. Since I have a history of a lesion free colon, the thought was if something is found they could go back later for a second go at it with a bridge. The standard process was inpatient bridging with heparin, so it saved them and me from a longer stay. Colonoscopy was a quick in and out (pun intended).
 

Gail in Ca

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I was told they could do the colonoscopy without lowering my INR, but if they found anything, they wouldn’t remove it. I would have another colonoscopy doing the lowering of INR and bridging. Prepping for possibly 2 colonoscopies sounded bad to me, so I got approval to do Cologard instead. I’m in chronic a-fib as well and the colonoscopy in the hospital option sounded risky with all the COVID there.
 

jeffp

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A follow up on Lovenox for those maybe later browsing through posts:
On the downhill side of the bridge, waiting for INR to get back up.
The shots are 0 fun. I’m a needle-phobic. Was all ready for the 1st stick - shaved and scrubbed my ample belly, got a good pinch, swabbed with alcohol, and held and wiggled the needle over area for a good minute before giving up. I don’t know how diabetics do this multiple times a day for a lifetime. I’m a mental wimp when it comes to needles. I can give them, just can’t take ‘em.
Back to the story…
I have some of those refreezable ice packs, both hard and flexible, and put one on the belly area for about a minute. Yup, it’s cold but not too bad. Swabbed the area, picked up my friendly syringe and kind of like dart, popped it in. Slowly further to about a mm or 2 from the hub and injected slowly. Like at a 20 seconds rate for the whole plunger. It has bit of a give when you get to the bubble. Kept the skin folded and pulled the thing out.
The ice numbs the skin just enough to greatly lessen the stick.
The stuff burns a bit going in, but tolerable (it’s the needles I fear, not the med). The burning increases a bit after the shot and continues letting you know it’s in there for about 30 minutes. Not enjoyable but I’ve had worse.
So far about a dozen shots, no bruising at all.
 

Chuck C

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I was told they could do the colonoscopy without lowering my INR, but if they found anything, they wouldn’t remove it. I would have another colonoscopy doing the lowering of INR and bridging. Prepping for possibly 2 colonoscopies sounded bad to me, so I got approval to do Cologard instead. I’m in chronic a-fib as well and the colonoscopy in the hospital option sounded risky with all the COVID there.
I opted for the Cologuard as well. It went well, negative.
 

Chuck C

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A follow up on Lovenox for those maybe later browsing through posts:
On the downhill side of the bridge, waiting for INR to get back up.
The shots are 0 fun. I’m a needle-phobic. Was all ready for the 1st stick - shaved and scrubbed my ample belly, got a good pinch, swabbed with alcohol, and held and wiggled the needle over area for a good minute before giving up. I don’t know how diabetics do this multiple times a day for a lifetime. I’m a mental wimp when it comes to needles. I can give them, just can’t take ‘em.
Back to the story…
I have some of those refreezable ice packs, both hard and flexible, and put one on the belly area for about a minute. Yup, it’s cold but not too bad. Swabbed the area, picked up my friendly syringe and kind of like dart, popped it in. Slowly further to about a mm or 2 from the hub and injected slowly. Like at a 20 seconds rate for the whole plunger. It has bit of a give when you get to the bubble. Kept the skin folded and pulled the thing out.
The ice numbs the skin just enough to greatly lessen the stick.
The stuff burns a bit going in, but tolerable (it’s the needles I fear, not the med). The burning increases a bit after the shot and continues letting you know it’s in there for about 30 minutes. Not enjoyable but I’ve had worse.
So far about a dozen shots, no bruising at all.
I'm glad that I didn't have to go through all of that for my thyroid procedure. The surgeon said it would be fine if I brought my INR down to I.5 with no need to bridge. Easy peasy if one self manages. There have been some recent published studies suggesting that this is safer than bridging. I believe it will probably keep moving in the direction of lowering INR vs bridging, except for the most major surgeries.
 

jeffp

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There have been some recent published studies suggesting that this is safer than bridging.
I’m behind on my journal reading. I’m finding the minority or articles on bridging involve mechanical valves. Lots of them on AF and DVT.
You have any links to these studies you mentioned? I’d love to run these past my cardiologist.
 

Chuck C

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Hi Jeff.

Per your request, please see the publication linked below. BTW, in getting my INR down below 1.5, I did not have to completely hold warfarin for even one day. I ended up going about 90% of my normal dose 2 days before surgery, 60% of my normal dose 1 day before surgery and about 23% of normal dose the day of surgery. I tested often to make sure I did not drop much below 1.5. This method also enabled me to bounce back quickly. The day after surgery I resumed my dosing with about 120% of my normal dose, taken in the evening.
The instructions the surgeon gave me were to be at under 1.5 INR the day of the procedure and to be under 2.0 for next day. After that my normal range of 2.0- 3.0 was fine. I ended up at 1.4 the day of procedure, 1.9 the next day and 2.3 two days after my procedure. I tested several times that week and as the procedure approached I would dose in the morning and then decide if I needed to dose again in the evening.

Pellicle has an entry in his blog in which he documents in more detail how I achieved this. I think in managing most people, they err on the side of going lower than I did. But, because I self manage and keep account of all my data, I know how quickly my INR drops when I hold or reduce my dosage. I burned through about $75 worth of test strips the week of my procedure, but I wanted to get below the INR level needed and not much lower, and the feedback enabled me to do this. $75 to lower my risk of a stroke or a bleed is peanuts. I would also note that I believe that I clear warfarin faster than most. I see a change in my INR the next day, either up or down, from even a small tweak to my dosage.

Also, it should be noted, both my cardiologist and the surgeon were on board with the plan. If I wanted to I could have bridged, but I had confidence that this would be lower risk than bridging. Bridging brings with it both thrombotic and bleeding risks. The risk is low, but real. From my perspective, the idea is to bring the risk from low to very low. For myself, I would rather spend one day at INR of 1.4 and know where I'm at vs the unknowns that bridging brings. The issue with bridging is that while the bridging agent is running the show, you don't know where you're at.
By the time of your procedure, your warfarin has been cleared from your system, and they hold the bridging agent. It has a very short half life and so at the time of the operation, you could be at the equivalent of 1.0 INR. That brings more risk of stroke than needed. If your team believes that 1.4 or 1.5 INR is sufficient, why risk going lower than that? Then on the other side of surgery, the bridging agent is resumed, at the same time warfarin is resumed. This brings with it some risk of having a bleed, as you are in a zone for a time where both agents are working to inhibit anticoagulation.


Here is the link to Pellicle's blog in which he documents what I did in more detail:

 
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jeffp

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Thanks for the link. Nothing new in there. I read with an interest in my particular situation. For aortic valvers having a minimal procedure (colonoscopy or dental work) dropping to a lower INR short term has minimal added risk. I do these with my INR in range. The maybe 1 or 2cc’s is about the same as a shaving cut (if I’m really not paying attention). For folks in my situation with a mitral replacement and having rectal surgery (very vascular area), according to the guidelines in the article (which are in agreement with pretty much the rest of the cardiovascular journals), a heparin bridge offers the shortest time of stroke risk. So we’re looking at essentially the same guidelines from different points of view.
 
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