No bridging between Heparin to Warfarin?

[NJWxMan]

Just wanted to see if anyone heard about this evidence based issue. My attending asked me to research this topic. Supposedly, he claims that there is literature that states that ther is no longer a need for a physician to start a patient on Heparin prior to their INR becoming therapeutic while taking both. Anyone know about this?

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[Medikit]

Just wanted to see if anyone heard about this evidence based issue. My attending asked me to research this topic. Supposedly, he claims that there is literature that states that ther is no longer a need for a physician to start a patient on Heparin prior to their INR becoming therapeutic while taking both. Anyone know about this?

I think your attending may have wanted you to do your search on pubmed

 

[muscles]

Found this on pubmed.

Arch Neurol. 2008 Sep;65(9):1169-73. Epub 2008 Jul 14

 

[jdh71]

Just wanted to see if anyone heard about this evidence based issue. My attending asked me to research this topic. Supposedly, he claims that there is literature that states that ther is no longer a need for a physician to start a patient on Heparin prior to their INR becoming therapeutic while taking both. Anyone know about this?

Here's how this conversation should go here:

"Hey guys! I've been asked to look some crap up . . . I found this and this and this and this, but I've been unable to find anything else. Does anyone know of anything else?"

Do your own work.

 

[MedicineDoc]

I am also interested in the topic. I have had several hip fracture patients started on coumadin by the hospitalists without heparin. I made a brief attempt at a literature search but was unable to find anything stating they didn't need to be bridged.

 

[drjitsu]

Just wanted to see if anyone heard about this evidence based issue. My attending asked me to research this topic. Supposedly, he claims that there is literature that states that ther is no longer a need for a physician to start a patient on Heparin prior to their INR becoming therapeutic while taking both. Anyone know about this?

I'm really not here to bag on anyone, but this is really not the place to ask these kinds of questions. For your own educational integrity, do the ground work on this sort of thing. Medicine is less about knowledge and more about knowledge acquisition. In other words, the knowledge of where to find information is more powerful than the information itself. Practice and become an expert at knowledge acquisition, interpretation, and application and you will reap the rewards, as will your patients and colleagues.

 

[BlackNDecker]

I am also interested in the topic. I have had several hip fracture patients started on coumadin by the hospitalists without warfarin. I made a brief attempt at a literature search but was unable to find anything stating they didn't need to be bridged.

I've not seen anyone at our hospital initiate coumadin without warfarin. However, I have seen some physicians start an epoxide reductase inhibitor without also giving a Vit K antagonist...

sorry, bored on call

 

[BlackNDecker]

I'm really not here to bag on anyone, but this is really not the place to ask these kinds of questions. For your own educational integrity, do the ground work on this sort of thing. Medicine is less about knowledge and more about knowledge acquisition. In other words, the knowledge of where to find information is more powerful than the information itself. Practice and become an expert at knowledge acquisition, interpretation, and application and you will reap the rewards, as will your patients and colleagues.

Agreed, all proper searches begin and end with "Wikipedia." Your patients will thank you.

 

[MedicineDoc]

Just saw the typo. should be heparin bridge. Anyway, knowledge is not just about looking things up it is also learning from other people. Having said that I would verify any information posted here before utilizing it.

 

[dragonfly99]

The info is in Pubmed.

Also, treatment guidelines by different medical societies are sometimes helpful to look at. I'm sure the hematologists have one r.e. this.

 

[c5a]

from my understanding (per Dr. Goljan, and step one was a while ago), when you start someone on warfarin, you are inhibiting factors II, VII, IX, and X. But you are also inhibiting protein C and S.

The first of these to be inhibited is protein C and S; it will take a few days for factors II, VII, IX and X to decrease. Protein C and S are ANTICOAGULANTS, so when you inhibit an anticoagulant first, you actually PROCOAGULATE them for the first few days. Hence you need the heparin for those first few days to bridge it.

 

[Medikit]

from my understanding (per Dr. Goljan, and step one was a while ago), when you start someone on warfarin, you are inhibiting factors II, VII, IX, and X. But you are also inhibiting protein C and S.

The first of these to be inhibited is protein C and S; it will take a few days for factors II, VII, IX and X to decrease. Protein C and S are ANTICOAGULANTS, so when you inhibit an anticoagulant first, you actually PROCOAGULATE them for the first few days. Hence you need the heparin for those first few days to bridge it.

That is the rationale behind bridging, however, clinical studies are beginning to question whether this is efficacious in all cases. Check out the September 2008 issue of Archives of Neurology.

 

[muscles]

That is the rationale behind bridging, however, clinical studies are beginning to question whether this is efficacious. Check out the September 2008 issue of Archives of Neurology.

Yeah, see the article I referred to above - the reference is listed up there.

 

[DarthNeurology]

I'm really not here to bag on anyone, but this is really not the place to ask these kinds of questions. For your own educational integrity, do the ground work on this sort of thing. Medicine is less about knowledge and more about knowledge acquisition. In other words, the knowledge of where to find information is more powerful than the information itself. Practice and become an expert at knowledge acquisition, interpretation, and application and you will reap the rewards, as will your patients and colleagues.

Well, there is a forum for discussing current concept in clinical care, i.e. recent journal articles so, I would disagree and say that it is OK to ask about a clinically debated issue in a group forum, this is the purpose of medical conferences, for medical experts to gather and discuss findings. You can read a book as well, or better find the right article, but asking questions here is also part of the educational process.

Never be ashamed to ask any question! The answers you get here may guide you to the appropriate source of knowledge.

Medicine is a lot about knowledge at some point too, anybody can look up stuff on the internet or in a journal article, I am sure the librarian with a master's degree at medical school can do an expert article search to help you with a paper on warfarin, but they aren't allowed to administer it. Because they don't have the whole medical knowledge base and experience. You can't rely on just being able to look up stuff or you will be very slow when taking care of patients.

ANYWAY, the article posted above was done in a specific subset of patients, i.e. those with cardioembolic stroke, is this generalizable to ALL patients who are put on warfarin? Probably not as some patients have a hypercoagulable state and might need heparin bridge as they might react to warfarin differently. There might be articles about heparin bridging as well and even evidence to demonstrate efficacy.

I think the above post makes a lot of generalizations and is more than a little patronizing, we ALL know how to do literature searches and how to read textbooks.

If you get pimped on rounds to name 10 hypercoagulable disorders and say you don't know but have the "power" to look it up in the library which is more "powerful" then you will get creamed.

 

[DarthNeurology]

I've not seen anyone at our hospital initiate coumadin without warfarin. However, I have seen some physicians start an epoxide reductase inhibitor without also giving a Vit K antagonist...

sorry, bored on call

Believe it or not but nobody in the world initiates coumadin without warfarin as they are the same medication. You must be a medical student, not that there is anything grossly wrong with that. I think epoxide reductase inhibitors can be experimental, something to replace warfarin so maybe that is why . . .

 

[Medikit]

Well, there is a forum for discussing current concept in clinical care, i.e. recent journal articles so, I would disagree and say that it is OK to ask about a clinically debated issue in a group forum, this is the purpose of medical conferences, for medical experts to gather and discuss findings. You can read a book as well, or better find the right article, but asking questions here is also part of the educational process.

Never be ashamed to ask any question! The answers you get here may guide you to the appropriate source of knowledge.

Medicine is a lot about knowledge at some point too, anybody can look up stuff on the internet or in a journal article, I am sure the librarian with a master's degree at medical school can do an expert article search to help you with a paper on warfarin, but they aren't allowed to administer it. Because they don't have the whole medical knowledge base and experience. You can't rely on just being able to look up stuff or you will be very slow when taking care of patients.

ANYWAY, the article posted above was done in a specific subset of patients, i.e. those with cardioembolic stroke, is this generalizable to ALL patients who are put on warfarin? Probably not as some patients have a hypercoagulable state and might need heparin bridge as they might react to warfarin differently. There might be articles about heparin bridging as well and even evidence to demonstrate efficacy.

I think the above post makes a lot of generalizations and is more than a little patronizing, we ALL know how to do literature searches and how to read textbooks.

If you get pimped on rounds to name 10 hypercoagulable disorders and say you don't know but have the "power" to look it up in the library which is more "powerful" then you will get creamed.

If the initial post had included some information from a previous search this would be an entirely different thread. I read the abstract in a mid-Nov issue of Jama and found it very interesting. Prior to responding I did a quick pubmed search and found that there were some great articles right on the first page.

Believe it or not but nobody in the world initiates coumadin without warfarin as they are the same medication. You must be a medical student, not that there is anything grossly wrong with that. I think epoxide reductase inhibitors can be experimental, something to replace warfarin so maybe that is why . . .

BnD is an intern, I think he just got a bit finger tied.

 

[brc12]

Whether bridging is necessary depends entirely on the initial indication for anticoagulation in the first place, which I don't believe you mentioned in your question.

 

[Trifling Jester]

Just wanted to see if anyone heard about this evidence based issue. My attending asked me to research this topic. Supposedly, he claims that there is literature that states that ther is no longer a need for a physician to start a patient on Heparin prior to their INR becoming therapeutic while taking both. Anyone know about this?

Depends what you're anticoagulating for.

-The Trifling Jester

 

[BlackNDecker]

Believe it or not but nobody in the world initiates coumadin without warfarin as they are the same medication. You must be a medical student, not that there is anything grossly wrong with that. I think epoxide reductase inhibitors can be experimental, something to replace warfarin so maybe that is why . . .

My humor was lost on you...

Warfarin = coumadin = epoxide reductase inhibitor = vitamin K antagonist.

 

[TommyGunn04]

...Supposedly, he claims that there is literature that states that ther is no longer a need for a physician to start a patient on Heparin prior to their INR becoming therapeutic while taking both. Anyone know about this?

From what I've been taught by several people throughout med school and residency, it depends on the indication. As was said above, warfarin makes a person transiently hypercoagulable by selectively depleting proteins C and S first, which are actually anticoagulant proteins that act on factor V. They have relatively short half-lives, thus when you give warfarin and inhibit vitamin K dependent clotting factor synthesis, the proteins with the shortest half-lives are the ones that run out first.

If you're just anticoagulating for prophylactic purposes, such as with atrial fibrillation, it's generally thought to be acceptable to not bridge with heparin or a LMWH to a therapeutic INR. The reason for this is that the theoretical clot risk in afib is exceedingly low -- only a few percent per year -- so the chances of you provoking a clot in the 3-5 days that someone is on their way to becoming therapeutic on warfarin is negligible. As such, it is felt that this small risk does not justify the cost, time, and inconvenience of using a bridge, and warfarin is just started as an outpatient.

On the other hand, if you're taking care of a patient who has a DVT or PE, the last thing you want to do is make them further hypercoagulable, even if just for a day or two. You want them therapeutically anticoagulated immediately, and want them to remain so until they no longer require treatment. This is why the bridge is thought to be important. Whether or not it actually pans out in terms of data though...that I'm not sure. I'd be curious to see what you come across in your PubMed searches. Last I checked, there were even some theoretical concerns that prompted hematologically oriented folks to recommend continuing the bridge for 48hrs after the INR is therapeutic even (which I rarely see done on the wards).

 

[DarthNeurology]

My humor was lost on you...

Warfarin = coumadin = epoxide reductase inhibitor = vitamin K antagonist.

Well, not all epoxide reductase inhibitors are warfarin, there are some experimental epoxide reductase inhibitors that are NOT warfarin that may replace warfarin. So your equation is not correct in that light.

But sad I didn't pick up on that nonetheless.

 

[Rendar5]

From what I've been taught by several people throughout med school and residency, it depends on the indication. As was said above, warfarin makes a person transiently hypercoagulable by selectively depleting proteins C and S first, which are actually anticoagulant proteins that act on factor V. They have relatively short half-lives, thus when you give warfarin and inhibit vitamin K dependent clotting factor synthesis, the proteins with the shortest half-lives are the ones that run out first.

If you're just anticoagulating for prophylactic purposes, such as with atrial fibrillation, it's generally thought to be acceptable to not bridge with heparin or a LMWH to a therapeutic INR. The reason for this is that the theoretical clot risk in afib is exceedingly low -- only a few percent per year -- so the chances of you provoking a clot in the 3-5 days that someone is on their way to becoming therapeutic on warfarin is negligible. As such, it is felt that this small risk does not justify the cost, time, and inconvenience of using a bridge, and warfarin is just started as an outpatient.

On the other hand, if you're taking care of a patient who has a DVT or PE, the last thing you want to do is make them further hypercoagulable, even if just for a day or two. You want them therapeutically anticoagulated immediately, and want them to remain so until they no longer require treatment. This is why the bridge is thought to be important. Whether or not it actually pans out in terms of data though...that I'm not sure. I'd be curious to see what you come across in your PubMed searches. Last I checked, there were even some theoretical concerns that prompted hematologically oriented folks to recommend continuing the bridge for 48hrs after the INR is therapeutic even (which I rarely see done on the wards).

Just curious, what about a patient with a newly diagnosed chronic DVT (had started 3-4wks prior) and pancreatic Ca. would you have been taught bridge or no bridge? This actually came up today and seemed to be a clash among people who had all been taught different ways of dealing with bridging and/or no bridging. I personally have never heard of the no bridge method at the different hospitals I've been at until today.

 

[elwademd]

Just wanted to see if anyone heard about this evidence based issue. My attending asked me to research this topic. Supposedly, he claims that there is literature that states that ther is no longer a need for a physician to start a patient on Heparin prior to their INR becoming therapeutic while taking both. Anyone know about this?

as mentioned in tommygunn04's excellent post, depends on indication for starting anticoagulation to begin with.

Just curious, what about a patient with a newly diagnosed chronic DVT (had started 3-4wks prior) and pancreatic Ca. would you have been taught bridge or no bridge? This actually came up today and seemed to be a clash among people who had all been taught different ways of dealing with bridging and/or no bridging. I personally have never heard of the no bridge method at the different hospitals I've been at until today.

if its a chronic dvt, you could argue that it doesn't need to be taken care of on the inpatient side... you might even find some people who would say that a chronic dvt doesn't require treatment... but then the patient has pancreatic cancer which i don't think anyone would argue isn't a hypercoaguable state/condition...

with that being said, i would imagine that at least a part of it depends on the patient's insurance. no insurance means you probably won't be able to send the patient home (with fragmin (dalteparin) and coumadin, for example) unless your hospital has some sort of set up/program that will give a patient 1-2 weeks of injectable lmwh agent.

if the patient has insurance, you might be able to do it all on the outpatient side. you'd be unlikely to do lmwh for life regardless of insurance status (though if it were me with a dvt, i'd rather have an injectable med and not have to worry about going to have my inr checked).

of course you also could argue for thrombolysis for the patient as well... yet another wrinkle.

 

[DRJIMPOL]

I have seen 3 middle aged patients who were treated with coumadin without proper heparin bridge DIE in the DOD mortality review system. That is 3 relatively young patients with protein C/S deficiency who were killed by their doctor who was trying to "be cost efficient" by saving a few lovenox injections based on "evidence based medicine"(NOT THE 10 commandments ...simply RECOMMENDATIONS by some group often via subjective, political motivations). We recommended suspensions of ALL 3 of these doctors , all 3 were sued by the Veterans' families and all 3 lost in court millions of dollars. If you want to possibly risk killing a patient and severly damaging your career/reputation, then don't pre-treat with heparin/lovenox. There are several Cardiologists who I NEVER consult because of this type of algorithm thinking. Think about it.

 

[michaelrack]

I have seen 3 middle aged patients who were treated with coumadin without proper heparin bridge DIE in the DOD mortality review system. That is 3 relatively young patients with protein C/S deficiency who were killed by their doctor who was trying to "be cost efficient" by saving a few lovenox injections based on "evidence based medicine"(NOT THE 10 commandments ...simply RECOMMENDATIONS by some group often via subjective, political motivations). We recommended suspensions of ALL 3 of these doctors , all 3 were sued by the Veterans' families and all 3 lost in court millions of dollars. If you want to possibly risk killing a patient and severly damaging your career/reputation, then don't pre-treat with heparin/lovenox. There are several Cardiologists who I NEVER consult because of this type of algorithm thinking. Think about it.

so you're saying that a doc's career should be ruined if he practices EBM but has a bad outcome??

Of course, I agree that each patient's individual circumstances must be taken into account.

 

[glorfindel]

I have seen 3 middle aged patients who were treated with coumadin without proper heparin bridge DIE in the DOD mortality review system. That is 3 relatively young patients with protein C/S deficiency who were killed by their doctor who was trying to "be cost efficient" by saving a few lovenox injections based on "evidence based medicine"(NOT THE 10 commandments ...simply RECOMMENDATIONS by some group often via subjective, political motivations). We recommended suspensions of ALL 3 of these doctors , all 3 were sued by the Veterans' families and all 3 lost in court millions of dollars. If you want to possibly risk killing a patient and severly damaging your career/reputation, then don't pre-treat with heparin/lovenox. There are several Cardiologists who I NEVER consult because of this type of algorithm thinking. Think about it.

Not helpful.

What were the patients being anticoagulated for? Why was the heparin bridge in their cases "proper?" What did the patients die of? End-stage fibromyalgia? Multiple gunshot wounds?

You haven't given us any useful information.

 

[Trifling Jester]

What did the patients die of? End-stage fibromyalgia?

Any ideas how to speed up that process?


-The Trifling Jester

 

[diphenyl]

Any ideas how to speed up that process?


-The Trifling Jester

Think the final cause of death for these people is either a nurse or doctor smothering them with a pillow.

 

[Bostonredsox]

you wont have to worry about a bridge soon. Rivaroxaban has achieved PE/DVT indication and should be used in most all patients who can afford it and it requires no bridge. Pradaxa has great data for the majority of patients for non valvular fib and requires no bridge nor monitoring. Again if they can afford it, get them off coumadin. Apixiban is coming soon and it proved superior to coumadin in all of the Afib outcomes and will likely get a valvular indication. If you research the fine details of most warfarin studies, the average time for a patient spent in the 'theraputic window in terms of INR" for coumadin, that is not supratheraputic nor underdosed, is 50-60% AT BEST. Add in the medicine interactions and diet restrictions plus monitoring and warfarin will be a drug of the past in the not too distant future.

But for now.....loading warfarin without bridging with LMWH or UFH is against guidelines. but as others have said, you need to look for the articles yourself.