UFH sc vs lovenox for warfarin bridging

[newtopharm18]

hello all
i am a new grad who just started to work as a perdiem pharmacist!
I am getting training and i have a question today
i learned for DVT/PT tx, we can use lovenox sc or UFH iv bolus/drip and warfarin until warfarin is in therapeutic INR level AND
for DVT/PT prophylaxis, we can use either lovenox sc or UFH sc 5000 q8 or q12 and warfarin until warfarin is in therapeutic INR level
but the rph training me called a resident for heparin sc to discontinue for warfarin initiation. i think she liked lovenox more the way she was asking to the dr but i wasn't sure bc i thought it was.. fine..??
i wanted to ask her but she is such a b+ i didn't want to
any reason why?
please help the new kid on the block!
thank you!

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[Carboxide]

hello all
i am a new grad who just started to work as a perdiem pharmacist!
I am getting training and i have a question today
i learned for DVT/PT tx, we can use lovenox sc or UFH iv bolus/drip and warfarin until warfarin is in therapeutic INR level AND
for DVT/PT prophylaxis, we can use either lovenox sc or UFH sc 5000 q8 or q12 and warfarin until warfarin is in therapeutic INR level
but the rph training me called a resident for heparin sc to discontinue for warfarin initiation. i think she liked lovenox more the way she was asking to the dr but i wasn't sure bc i thought it was.. fine..??
i wanted to ask her but she is such a b+ i didn't want to
any reason why?
please help the new kid on the block!
thank you!

Most practitioners prefer to have therapeutic anticoagulation instead of prophylaxis levels when bridging to warfarin, both because warfarin is initially pro coagulating and also because if a patient needs therapeutic anticoagulation to prevent DVT, they are probably pretty high risk to clot. It is very common to bridge with therapeutic lovenox, even for ppx.

 

[confettiflyer]

For DVT/PE, our pt’s are usually initiated on IV heparin or therapeutic Lovenox on admit. VKA is typically added a bit later after full work up, but SC ppx dose heparin is ineffective for this indication.

If this was an afibber, we typically don’t bridge unless they’re high risk (again, full dose). So if that SC heparin + VKA happened on a low risk/new onset, I’d probably let the DVT ppx heparin go and follow up when INR > 2 for d/c (or page for d/c parameters).

I think *technically* you can bridge w/SC heparin outpt with high weight based dosing, but I’ve never come across that.

And welcome to the show! Inpatient is fun, you’ll get better as the days roll by.


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[newtopharm18]

Thanks for the replies!
So we generally don’t use px dose of lovenox at all with warfarin? Bc i have seen that combo multiple times.
So i was wondering in my mind if you are going to use lovenox px dose with warfarin, why can’t we use heparin 5000u sc q8 or q12.
Yes. I agree, inpatient is definitely interesting! Learning new things every single day

 

[bacillus1]

Thanks for the replies!
So we generally don’t use px dose of lovenox at all with warfarin? Bc i have seen that combo multiple times.
So i was wondering in my mind if you are going to use lovenox px dose with warfarin, why can’t we use heparin 5000u sc q8 or q12.
Yes. I agree, inpatient is definitely interesting! Learning new things every single day

No need to bridge for a. fib, and you have warfarin on board, so it's unnecessary to give another medication (heparin sq or lovenox ppx), especially if that medication increases bleeding risk. Therefore, we always pull off the ppx when initiating warfarin.

As far as heparin vs. lovenox ppx otherwise, they cost about the same and lovenox is easier for nurses to administer, so we prefer lovenox for non-renally-impaired patients but will still give heparin if the MD wants it.

 

[Rockinacoustic]

Thanks for the replies!
So we generally don’t use px dose of lovenox at all with warfarin? Bc i have seen that combo multiple times.
So i was wondering in my mind if you are going to use lovenox px dose with warfarin, why can’t we use heparin 5000u sc q8 or q12.
Yes. I agree, inpatient is definitely interesting! Learning new things every single day

Your patients on Lovenox prophylaxis and warfarin are either being given an unnecessary additional bleeding risk or at increased risk for thrombosis depending on the indication. You should review the CHEST antithrombotic therapy guidelines.

 

[Dred Pirate]

Your patients on Lovenox prophylaxis and warfarin are either being given an unnecessary additional bleeding risk or at increased risk for thrombosis depending on the indication. You should review the CHEST antithrombotic therapy guidelines.

this x1000 - either do it right - give tx dose lovenox or UFH (either has their role) or or nothing - you could make a slight argument that warfarin is pro-thrombotic for the first day or two and that prophy lovenox reduces this risk.

ultimately (as far as I know - I am not a cards specialist) it comes down to risk vs benefit on a case by case basis -not sure if the guidelines are overly strong on either way (chads2-vasc and hasbleed scores, etc)

 

[newtopharm18]

this x1000 - either do it right - give tx dose lovenox or UFH (either has their role) or or nothing - you could make a slight argument that warfarin is pro-thrombotic for the first day or two and that prophy lovenox reduces this risk.

ultimately (as far as I know - I am not a cards specialist) it comes down to risk vs benefit on a case by case basis -not sure if the guidelines are overly strong on either way (chads2-vasc and hasbleed scores, etc)

No this is what I meant. Of course I don’t want pt to be on both ppx lovenox or heparin with warfarin for a long time. For 1-2 days until pt’s INR is in the range. My question is on that short period of days, why is generally lovenox is okay but heparin isn’t. (Well at least the rph training me, she doesn’t think so). Or is it generally no for both lovenox and heparin all the time..?

 

[naseuy]

Why are you giving a prophylactic dose of heparin for for someone who already has an active DVT/PE?

 

[Dred Pirate]

No this is what I meant. Of course I don’t want pt to be on both ppx lovenox or heparin with warfarin for a long time. For 1-2 days until pt’s INR is in the range. My question is on that short period of days, why is generally lovenox is okay but heparin isn’t. (Well at least the rph training me, she doesn’t think so). Or is it generally no for both lovenox and heparin all the time..?

I think we are misunderstanding each other - heparin is perfectly fine to bridge therapy with - whether it is needed or not depends on patient specific criteria

 

[Dred Pirate]

Why are you giving a prophylactic dose of heparin for for someone who already has an active DVT/PE?

i think the op is mentioning two difference sceneiros - one is dvt prophy and one is active - if active - of course, you need to bridge

 

[naseuy]

i think the op is mentioning two difference sceneiros - one is dvt prophy and one is active - if active - of course, you need to bridge

"but the rph training me called a resident for heparin sc to discontinue for warfarin initiation. i think she liked lovenox more the way she was asking to the dr but i wasn't sure bc i thought it was.. fine..??"

What I got from the scenario was that the patient was on SC heparin and pharmacist called to change to therapeutic dose of lovenox for bridging which makes sense.

 

[newtopharm18]

I think we are misunderstanding each other - heparin is perfectly fine to bridge therapy with - whether it is needed or not depends on patient specific criteria

This is what I needed! Thank you

"but the rph training me called a resident for heparin sc to discontinue for warfarin initiation. i think she liked lovenox more the way she was asking to the dr but i wasn't sure bc i thought it was.. fine..??"

What I got from the scenario was that the patient was on SC heparin and pharmacist called to change to therapeutic dose of lovenox for bridging which makes sense.

Nonono... not to therapeutic lovenox dose but she just didn't like heparin sc so she wanted to change lovenox ppx instead and I didn't get that
I thought there is some kind of a reason for her to favor lovenox ppx over heparin sc ppx
thank you again though!

 

[confettiflyer]

This is what I needed! Thank you


Nonono... not to therapeutic lovenox dose but she just didn't like heparin sc so she wanted to change lovenox ppx instead and I didn't get that
I thought there is some kind of a reason for her to favor lovenox ppx over heparin sc ppx
thank you again though!

Maybe the pharmacist didn’t want to stab the patient 2-3x a day? Haha, the only other reason I can think of is Lovenox is preferred in cancer pt’s, but data is limited, and if UpToDate is your only ref, it’s there plain as day (Lovenox > UFH in cancer pt’s for VTE in CHEST I believe).

But ESMO guidelines don’t prefer one over the other, but that last update was 2011.

Did that pt have a history of malignancy?


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[naseuy]

Is the patient obese?

 

[positivesign]

Uptodate cites several meta-analyses where the use of LMWH resulted in less incidences of DVT vs. UFH with no difference in bleeding. Perhaps this is why?
(UpToDate)

 

[newtopharm18]

Maybe the pharmacist didn’t want to stab the patient 2-3x a day? Haha, the only other reason I can think of is Lovenox is preferred in cancer pt’s, but data is limited, and if UpToDate is your only ref, it’s there plain as day (Lovenox > UFH in cancer pt’s for VTE in CHEST I believe).

But ESMO guidelines don’t prefer one over the other, but that last update was 2011.

Did that pt have a history of malignancy?

I don't remember but good info to know!

Uptodate cites several meta-analyses where the use of LMWH resulted in less incidences of DVT vs. UFH with no difference in bleeding. Perhaps this is why?

I guess so. We use lexi and uptodate so maybe this is where she got her information.
Very good information to know as well.
Thank you.

 

[NITRAS]

Your patients on Lovenox prophylaxis and warfarin are either being given an unnecessary additional bleeding risk or at increased risk for thrombosis depending on the indication. You should review the CHEST antithrombotic therapy guidelines.

I'm sorry, did I miss it. Does a subtheraputic INR with coumadin decrease the incidence of DVT/PE in medical patients?

As to IV heparin vs. therapeutic Lovenox,. . . I hate IV heparin. I only use it when I have to. I actually just use apixaban if I can.

 

[Rockinacoustic]

I'm sorry, did I miss it. Does a subtheraputic INR with coumadin decrease the incidence of DVT/PE in medical patients?

Huh?

 

[naseuy]

This is what I needed! Thank you


Nonono... not to therapeutic lovenox dose but she just didn't like heparin sc so she wanted to change lovenox ppx instead and I didn't get that
I thought there is some kind of a reason for her to favor lovenox ppx over heparin sc ppx
thank you again though!

" DVT/PT prophylaxis, we can use either lovenox sc or UFH sc 5000 q8 or q12 and warfarin until warfarin is in therapeutic INR level
but the rph training me called a resident for heparin sc to discontinue for warfarin initiation."

Wait are you guys using warfarin for primary prophylaxis? I'm confused.

 

[ldiot]

We bridge people with afib all the time if they are high risk based on CHADS2