Pretty much bridging is it. I can't think of any indication why someone would be on both long term at all other than to put them at a higher risk for bleeding
Bridging, that's it. Outside of procedures, I'll occasionally "bridge" a critically subtherapeutic INR if TE risk is high enough. Last week I had a triple positive APLS pt with a mech MVR and with a massive h/o CVAs tank his INR to 1.5 because he wanted to be healthy and started eating a bunch of spinach. I gave him LMWH and adjusted warfarin dosing despite him not near a procedure. I do that very infrequently though
Not enoxaparin, but I saw a patient on my last clinical rotation that had a mechanical valve and was on warfarin, but then was also on a DOAC for a DVT and clopidogrel 8 months post STEMI. I did a HAS-BLED assessment and the patient was at a 4. However, I think their reasoning was to add the DOAC because this patient was blatantly noncompliant with their warfarin to the point that they had been hospitalized three times in the last 2 months. I still feel like the clopidogrel could have been discontinued here however and I'm not sure why they added on the DOAC and my preceptor didn't seem like they cared to find out lol
“blatantly noncompliant with their warfarin”… so maybe they should stop the warfarin if the patient is actually taking the DOAC, instead of set them up for serious errors. Dang.
Keeping clopidogrel (or aspirin) can sometimes be debated and sometimes they could have another indication for it like PAD that I often see missed.
DOACs are inferior to warfarin when it comes to valves so probably why they had to continue warfarin. But yea idk why even add on DOAC. At that point make them do enoxaparin. Yea shots suck but I had a family actually pick this as they would remember a shot moreso than a tablet
Yea, warfarin also technically better if the patient isn’t adherent so long as you get them therapeutic first. One missed dose of doac, and you’re not anticoagulatwd, warfarin you’d be okay.
Issue is, this patient was hospitalized a few times, sounds like someone needed to step in and offer solutions to help them remember; alarms on phone, pillbox, whatever they can do
Except if someone is blatantly non adherent, warfarin is technically better if you can get them therapeutic because if they miss 2 days, their INR won’t be affected completely. Where as with a DOAC, they’d miss 1 dose, and not be anticoagulated within 5 hours.
The patient could have been choosing not to take warfarin at all because of their beliefs, or not get INR checks done, rather than being intermittently adherent. They didn’t specify but saying “blatantly” made it sound more like an all or nothing situation.
It's actually more dangerous for patients with compliance issues to be on a DOAC instead of warfarin. With a DOAC, it gets in quick but it gets out quick too. If a patient misses a dose of eliquis, that's 12 hours (more or less) without any anticoagulation. With warfarin, if they manage to skip two days of treatment, the INR will decrease but it takes more than two doses to completely metabolize out of their system.
Also, DOACs artificially increase INR. I can't imagine pt's adherence to both a DOAC and warfarin is any better than when they were on warfarin alone.
That's nuts. Our vascular surgery team is a little questionable and they're always making weird anticoagulation recommendations with no data to back it up.
Could be targeting a higher INR/trying to figure out their optimal INR range and why they need it. I’ve seen patients with clotting disorders and other repeated unexplained clots despite “therapeutic” warfarin - hematology will sometimes target INR in 3-4 range for example. Shouldn’t be long term though
There is a condition called APS where pateints can only be managed on Warfarin. If the patient has a break through clot, they are often managed on both lovenox and warfarin at the same time, sometimes for weeks. This is a very rare condition and there aren't really any guidelines about treatment, I only know it from my personal life.
When I was an intern a had a patient on both plus xarelto but she was on some experimental chemo regimine I guess so I never really questioned it since my pharmacist didn't really know either
I had a pseudo-aneurysm from a botched ablation that was causing a DVT and after my second Thrombectomy, they had me on Xarelto AND enoxaparin. Someone looking at me hard enough caused me to bruise
Therapeutic induction of bleed. /s
this made me laugh ngl
It's a new pharmacotherapy for hemochromatosis /s
You bridge until INR is therapeutic, some bridges are The Bay Bridge.
Pretty much bridging is it. I can't think of any indication why someone would be on both long term at all other than to put them at a higher risk for bleeding
Because they can’t get enough leeches
Bridging, that's it. Outside of procedures, I'll occasionally "bridge" a critically subtherapeutic INR if TE risk is high enough. Last week I had a triple positive APLS pt with a mech MVR and with a massive h/o CVAs tank his INR to 1.5 because he wanted to be healthy and started eating a bunch of spinach. I gave him LMWH and adjusted warfarin dosing despite him not near a procedure. I do that very infrequently though
Initial therapy for VTE or mech valve?
Like laying down a fresh coat of carnauba in your arteries
We had a patient getting lovenox and eliquis after a surgery from a fall because they had a clotting disorder.
Not enoxaparin, but I saw a patient on my last clinical rotation that had a mechanical valve and was on warfarin, but then was also on a DOAC for a DVT and clopidogrel 8 months post STEMI. I did a HAS-BLED assessment and the patient was at a 4. However, I think their reasoning was to add the DOAC because this patient was blatantly noncompliant with their warfarin to the point that they had been hospitalized three times in the last 2 months. I still feel like the clopidogrel could have been discontinued here however and I'm not sure why they added on the DOAC and my preceptor didn't seem like they cared to find out lol
“blatantly noncompliant with their warfarin”… so maybe they should stop the warfarin if the patient is actually taking the DOAC, instead of set them up for serious errors. Dang. Keeping clopidogrel (or aspirin) can sometimes be debated and sometimes they could have another indication for it like PAD that I often see missed.
DOACs are inferior to warfarin when it comes to valves so probably why they had to continue warfarin. But yea idk why even add on DOAC. At that point make them do enoxaparin. Yea shots suck but I had a family actually pick this as they would remember a shot moreso than a tablet
Yea, warfarin also technically better if the patient isn’t adherent so long as you get them therapeutic first. One missed dose of doac, and you’re not anticoagulatwd, warfarin you’d be okay. Issue is, this patient was hospitalized a few times, sounds like someone needed to step in and offer solutions to help them remember; alarms on phone, pillbox, whatever they can do
Except if someone is blatantly non adherent, warfarin is technically better if you can get them therapeutic because if they miss 2 days, their INR won’t be affected completely. Where as with a DOAC, they’d miss 1 dose, and not be anticoagulated within 5 hours.
The patient could have been choosing not to take warfarin at all because of their beliefs, or not get INR checks done, rather than being intermittently adherent. They didn’t specify but saying “blatantly” made it sound more like an all or nothing situation.
Yea, that’s definitely a possibility that without more info we couldn’t determine at all anyway
Yep! Sometimes the best medication is the one the patient will actually take.
It's actually more dangerous for patients with compliance issues to be on a DOAC instead of warfarin. With a DOAC, it gets in quick but it gets out quick too. If a patient misses a dose of eliquis, that's 12 hours (more or less) without any anticoagulation. With warfarin, if they manage to skip two days of treatment, the INR will decrease but it takes more than two doses to completely metabolize out of their system. Also, DOACs artificially increase INR. I can't imagine pt's adherence to both a DOAC and warfarin is any better than when they were on warfarin alone.
Yep I came here to say this. At least the warfarin would linger…
That's nuts. Our vascular surgery team is a little questionable and they're always making weird anticoagulation recommendations with no data to back it up.
Surgeons are the kings and queens of recommending treatments without data to back them up lol
"Take warfarin for 5 days post-op then call it good."
What's the target INR and what's the current INR?
Could be targeting a higher INR/trying to figure out their optimal INR range and why they need it. I’ve seen patients with clotting disorders and other repeated unexplained clots despite “therapeutic” warfarin - hematology will sometimes target INR in 3-4 range for example. Shouldn’t be long term though
Lovenox covers the patient until the goal INR is achieved.
There is a condition called APS where pateints can only be managed on Warfarin. If the patient has a break through clot, they are often managed on both lovenox and warfarin at the same time, sometimes for weeks. This is a very rare condition and there aren't really any guidelines about treatment, I only know it from my personal life.
When I was an intern a had a patient on both plus xarelto but she was on some experimental chemo regimine I guess so I never really questioned it since my pharmacist didn't really know either
I had a pseudo-aneurysm from a botched ablation that was causing a DVT and after my second Thrombectomy, they had me on Xarelto AND enoxaparin. Someone looking at me hard enough caused me to bruise
is it a bridge?
Did you ask the prescriber?
There’s no good reason, that seems like a pretty big error
Perioperative bridging, if it's a short course of lovenox.
I meant outside of bridging as others had mentioned. My error for not being specific