Lovenox, Heparin, and Mr Clot
Its very rare that I rag on an entire healthcare system. I don't expect anything to be perfect (except myself of course.. :) ) and my standards for nurses is at an all time low, so you impress me if you can manage to pronounce 'Atenolol' correctly.
Today however, I completely lost my faith in a particular health care system. Now I wont tell you which group this doctor came from (it rhymes with Kaiser), but heres how it all went down.
I get this phone call from a nurse at a local hospital here in town. She is calling in discharge medications for a patient who recently had hip surgery. She calls in 100 vicodin (of course), and Lovenox given once a day for a month. Now I can see all of the retail pharmacists assholes puckering at the cost of a month of Lovenox, and I can see all of you "I'm Mr Clinical Hospital Pharmacist, look at my fancy pants and PharmD title! Call me doctor!" chumps roll your eyes. Oh no, it gets better.
I politely tell the nurse that there must be a mistake. First off, Lovenox is given twice a day (its half-life is 12 hours). Second, no doctor who graduated medical school would give it for an entire month. Lovenox really isnt designed nor intended for that! The nurse politely told me that this was a Kaiser doctor, and thats what was ordered. I asked the nurse to page the doctor, it was time for some schooling!
For all you students and non-pharmacists out there, heres what the problem is.
When you get any hip surgery, they usually put you on some sort of anticoagulant (such as Coumadin) to prevent a clot from getting stuck in your noggin or your lungs. The problem is that Coumadin takes about 5 days (60 hours or something like that) after you start taking it to start working. Coumadin inhibits your body from producing clotting factors (its a Vitamin K analog that Taliban's the clotting factories), and some of those clotting factors hang around for a few days before your body coat hangers their life and recycles their little innards. So you need to wait until the existing clotting factors are cycled out so your body cant produce more (because of the Coumadin). With me? Good! You now know more than this doctor does.
Now in the hospital, nurses give the patients Heparin to prevent clotting. Heparin does magical things with your existing clotting factors to make them stop clotting. They don't inhibit the production of the clotting factors. The problem with heparin is that it causes this nasty condition called Heparin Induced Thrombocytopenia (HIT) that basically makes you stop producing platelets. Bad news. So they only give heparin in the hospital so they can watch you die vs having you die at home. You may be asking "Why cant they give Coumadin before surgery?". Ah, if you bleed out on the operating table because you're loaded up with Coumadin, that tends to make your family less than happy.
So in steps Lovenox. Its a Low Molecular Weight Heparin which doesn't cause HIT, thereby it can be given at home. Person gets a shiny new Rx for Coumadin and Lovenox, starts taking the Coumadin while giving themselves shots of Lovenox twice a day for 5 to 10 days, then when they have used up the box of Lovenox their Coumadin has already started working and you're good to go. Its called "Bridge Therapy" because Lovenox acts as a 'bridge' between Heparin in the hospital and Coumadin tablets at home.
Now you can impress your friends and family with useless pharmacy knowledge. If I got any of the above wrong, blow me, its 2:30am on a Friday night/Sat Morning, and I'm sitting here in front of my computer sober rather than asleep or drunk.
So the doctor calls back. He asks what the problem was. I explain my problem with his orders and he still doesn't get it. His excuse for the month of Lovenox: "The patient wasnt going to be seen at Kaiser, so she'll have to use this". Yeah, riiiiight. As if any insurance company is going to say "Sure! I'll pay $3000 for a month of Lovenox vs $30 for a month of Coumadin!" So I explain to him that maybe we should just do a 10 day run, and she can go and see her primary care for Coumadin therapy. Nope, wanted a month of Lovenox at once/day. So now I bring out the big guns. I ask him why he is giving it once daily, when the half-life is 12 hours? Stammering and silence on the phone. Then a "This is how we do it at Kaiser". Bull-Fucking-Shit. I guess if thats the case, they are spending all of their cash on Lovenox and not on hiring decent doctors. After much 'this is how its going to be' and basic pharmacology lesson of Coumadin and Lovenox, I manage to get him to do what I say and authorize a 10 day run at twice daily. Patients life has been saved thanks to yours truly. I slammed down the phone, and waved my pharmacology penis all around for everyone to see.
This is basic shit. This isn't a super complex protocol. Its not like we are putting her on a MAO-I *shudder* or even titrating up her Coumadin! Maybe I put too much faith in doctors in knowing their medications. Oh, and to any of the pharmacists at Kaiser who might be reading this, just don't get me in trouble. :)
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Vote for me!
ever thought of leaving your job? You don't sound like a pleasant person to work with, nor a pleasant pharmacist at all. You sound profoundly disapointed in your life and really should get into something else for both your sake and your customers.
Hey, that was pretty good. Now I know just a teeny bit more about the fake doctoring they do on Scrubs when one of the attendees gets rid of an intern by having him/her go treat a patient with Thrombocytopenia. Not that paying attention to their medical jargon is educational. In fact it's very inconsistent. Several times a character has mentioned a problem or a need to visit a patient with Necrotizing Fasciitis, yet in one episode diagnosing this very same problem is a "one in a million shot." Go figure.
Generic names please! Makes life so much easier from the other side of the pond.
Yes doctors are bad (prednisolone 10mg four times a day anyone, long acting beta agonists with no corticosteroids) but nurses and dentists are even worse (metronidazole 400mg qds) as they have even less pharmacology knowledge.
MAO-I= nasty nasty nasty
adjusting warfarin dose = fairly easy, as long as you check INR in a week.
Michelle, this post was written tongue in cheek. Sarcasm, ya know?
If you had any idea what actually happens day to day in a pharmacy, you would understand exactly why he posted this entry.
In case you have not read the memo: There is more to filling a prescription than putting pills into a bottle and slapping a label on it. A pharmacists job is to make sure what your doctor has prescribed you will not interact with any of your other medications, not make you swell up like a ballon because of an allergic reaction and make sure your doctor actually knows what he is doing, and doing it right. Patient care comes before everything else. It is the reason why we do the things we do day in and day out.
There are reasons why burnouts are so common in our profession, and ignorance is one of them.
Hi angrypharmacist...just wanted to comment to Michelle who commented previously - don't read 'theangrypharmacist' blog and tell him to get into a new line of work! Those of us who are in the profession understand where he's coming from and appreciate that someone out there rants it up and make us all feel like we're not the only ones who get the short end of the stick!
As for your Dr. Kaiser, you have to wonder about some people! I'm glad you stuck to your guns and got it changed...no matter how frustrating it was!
I've actually seen Lovenox given 40 SC qd as a prophylactic dose. I've also seen Lovenox given for longer than that in pregnancy (obviously can't take warfarin while prego). Neither of those situations seem to be applicable here...just another jerkoff doctor who doesn't know a damn thing about anticoagulation and just listens to drug reps for updating his knowledge on medicine. Haha.
Got an Rx from an ER doc the other night that was as follows (mind you for one, 120 pound, patient)
Perc 7.5 1QID
Lortab 5 1Q4-6HPRN
Soma (Of course) 1Q4-6HPRN
Now lets play a game, whats wrong with these Rxs? :P Sometimes I wanna kick the docs in the face lol
Had this sent to me by a resident I train. I am a hospitalist. Angry pharmacist. Can you come work where I do? I wanna get a beer with you. Damn funny. Sorry you have to put up with pricks who wont collaberate just dictate. Seriously, damn funny. Thanks for the read and re-ed on anticoagulants.
Great post especially the Warfarin pharmacology, Just thought I'd add some clarification.
While the usual dosing for Enoxaparin (Lovenox) is 1mg/kg twice a day, it depends on the indication.
Prophylactic dosing for prevention of thrombo-embolism is actually 1mg/kg once a day.
There are also some recommendations that it can also be dosed 1.5mg/kg once a day even for therapeutic indications.
So while I don't agree with giving it for a whole month, the doctor may in fact be using a 1.5mg/kg formula in order to reduce dosing frequency.
I would have to agree with you on your assessment oof the duration of the prescription, but I, personally, am in a situation that requires Lovenox every day, and have been taking it now for 6 months. I developed an toxic reaction to Coumandin and bled out three units of blood through my skin. THERE ARE EXTENUATING CIRCUMSTANCES THAT REQUIRES EXTENUATING PROCEDURES! YOU OUGHT TO KNOW THIS!
thank you to the angry pharmacist....i am a nurse.....a little older now and i am amazed at what the so called newer doctors don't know about medicines....I've had my share of going rounds and rounds with them ...one day i was actually told that i am "here to do, not to think"!! i said to him that as long as i have a brain i'm going to use it....and i will protect my patients from him....i was surprised that i wasn't fired. You were right on the money, thank you for helping us do our jobs properly and keeping the doctors from killing their patients....hugs
give me a break. maybe he patient is going to get a series of epidural shots...
and yes enoxaparin can cause HIT.
read it.
I hate to burst your bubble because I like to read your blog, but there are a few things untrue about what you said regarding enoxaparin (Lovenox):
1. Given as a prophylactic, enoxaparin can be dosed once a day (40mg SQ daily) or in treatment of DVT/PE 1.5mg/kg. (this was already mentioned)
2. Enoxaparin can indeed cause HIT just like heparin (after all, its made out of the same stuff LMWH = low molecular weight HEPARIN). Its just a little less likely than heparin to cause it. (Only slightly)
3. You are wrong about why heparin is given in an inpatient setting, this is done to monitor aPTTs (except for prophylactic doses), CBCs, and heparin levels (because heparin gives you a wide, variable response because its huge, and binds to proteins in your body). Enoxaparin can be given in an outpatient setting and gives a more predictable response so it doesnt require aPTTs but still requires periodic CBCs to monitor for HIT.
4. Enoxaparin can be given long term if you like the risk for osteopenia, but you are right that warfarin is better (because its effective and cheaper) given as a prophylactic. However, certain patients (pregnant, liver failure, skin necrosis in the past, cant achieve a therapeutic INR (too high/low), risk for hemorrhage which would outweigh treatment with warfarin) require different treatment (enoxaparin is usually preferred here). I assume since the doctor couldnt answer why he picked enoxaparin that it wasnt a good choice so your recommendation was most likely correct. But what if he did have a reason? Would you have posted about how he embarrassed you in front of your staff? They can be pretty mean at times.
5. Bridge therapy with concurrent enoxaparin MUST be given for MORE than 10 days if the patient doesnt reach a therapeutic INR in the time (and for at least 5 days). (say for instance in a heavy drinker with a normal 5mg starting dose probably wont be going therapeutic anytime soon)
6. Youre wrong about Pharm Ds; not all of them wear fancy pants (I wear plaid) ;-)
I know you may not post this (I understand if you dont), but I hope you at least read it and maybe send an email telling me what you think. Sorry if it seems rude, trying to think at 2:30am does suck.
Well Angry PHD,m
just a little note this Dr. did you a favor
is you read the ACCP (American Colledge of chest physicians)Guidlines you will find the that lovenox is actually indicated 40MG for dvt PRX in hip for 28-35 days. you may want to call this Physician back and thank him
Lovenox can be given at 1 mg/kg q24h if the patient requires renal adjustment. Lovenox does cause HIT. In the case of HIT, another option such as Arixtra could be chosen. As for the supply of one month, I'd have told the doctor the cost to the patient, then partially filled whatever amount the insurance would cover and let the patient follow-up with their physician or come back if they needed more.
Sir,
I wanted to write you a note in regards to Lovenox. There are some people out in the world that have genetic DNA mutations in regards to being thrombophilic and hypofibrinolytic.
1.) being heterozyogsity for the G1691A mutation in the Factor V Gene(Factor V leiden. (increased tendency to clot.)
2.)being heterozygosity for the platelet glycoprotein gene. This is thrombophilic (increased tendency to clot)
3.) Homozygosity for the 4G4G polymorphism of the PAI-1 gene and hetrozygosity of the 4G/5G genotype. This hypofibrinolytic (can't chop up clots well)
4.) High Lp(a) This is hypofibrinolytic.
All of the above in laymens terms means that my blood clots easily and once it does my body can't chop up the clots to-wit: causes secondary illness' including (IH (intercranial hypertension), I can't have a shunt due to fact I throw clots when cathers are put into my body. Even something as simple as getting blood tests taken I have a clot at the puncture site.I have other secondary illness'as well but that list is long enough that it rivels the book War and Peace. I volunteered to be a lab rat in 2004 trying medications to put these problems in possible remission but guess what it didn't work for my mutated ass. So I have now decided, along with my physicians to go on extended Lovenox treatment 60mg 2 x a day for a three month trial. I have read some of your articles in regards to people being put on home treatment, I am having a home nurse come to teach me and my family members which consists of (2) the others are all dead,on how to properly inject this medication per my doctors orders.I understand the published risks. I like the fact that you are so blunt and honest but there are a few people in this world that are walking mutations like me.This is a chance I am willing to take and see if it is an appropriate treatment me.I have been mad, seething, even sometimes vicious towards the medical community. I fought for (7) years until I found a a Doctor who knew his Shit and did the DNA PRC and coagulation testing on me in 2004.He's into research and has been very successful in his prior studies with other people. I'm not normal, the normal treatment didn't work, it's been 3 years now on the normal treatment. It has been 10 years now total since I began being ill and so I have made the choice to try the long term Lovenox injections. You have an articulative opinion and I respect your knowledge but sometimes there are fuck ups like me. Where taking a chance is better than slowly watching myself die. I'm 38, no children I was smart enough not to keep this mutation going, whether it's a smart move or idiotic it's better than doing nothing. The medication I'm on reads more like a purchase order sent in to restock a pharmacy. So with diplomacy I ask for some information from you that you have seen and experienced with Lovenox.I like to hear every side to a subject and I would appreciate your input. I would rather die fighting than to be a chicken shit and hide in a corner. I know this doesn't matter to you but I have a saying I now live by :"SOMETIMES DOING THE RIGHT THING IS NOT DOING THE RIGHT THING".I truly would appreciate it if accept my invitation to e-mail your response.
Like KtimpedOne, I have been on long term Lovenox sine Oct99 = 100mg twice a day. Coumandin failed me twice with PEs while INR was > 14. I reaslise there are side effects for long term, however what you stated as for the doses was correct.
I have a question about Lovenox ... can not find the answer anywhere else.
What are the side effects when Lovenox is given IV for several days.
Thanks
recommend you look up how
"hit" works. it has nothing to do with the production of platelets but rather the consumption. thank goodness the real pharm d corrected you on all your other erroneous statements regarding enoxaparin.
I just did the Lovenox/Coumadin "bridge" for bilateral PE (nooooo, I can't have just one, too easy!). Thank you for explaining the whole bridge thing, it makes the process much more comprehensible. And, as a retired medical assistant to a sensible pharmacist, I LIKE you!!!
I have been on Lovenox twice daily for the past 8 weeks.I have one gene in the V-Leiden factor (predisposition to blood clotting about 3-8 X more than normal humans. This was discovered when a spinal tap and full bloodwork was performed to test me for MS. I previously had one blood clot which was treated and monitored with Coumadin for nearly one year.
Recently had an accident and had to have extensive foot surgery. Recouperation so far 2 months in cast with no pressure on foot so more or less bedbound as using crutches or walker out of question. I have two more weeks to go before physical therapy. I have been on Lovenox 30mg/0.3ml every 12 hours from the day of the accident which to date is 2 months. I have 2 more weeks to go and yes, we had to pay the full price for it which is something over $3,000 so far. Now I am worrying because I have been on it for 8 weeks already. What worries me also is that 2 years ago I had a dieulafoy lesion and had to have a blood transfusion because I lost so much blood from the bleeding artery in my stomach (not an ulcer). Nobody knows what causes that.
Lovenox can also cause HIT if the patient has had HIT previously while being treated with heparin. (just an FYI) from some "stupid doctor".
Interesting to read. I am pregnant, I have 3 genetic clotting disorders, and I take Lovenox once a day along with a baby aspirin. Lovenox sustained my last pregnancy, and seems to be quite effective at sustaining this one. Before I started Lovenox I had five miscarriages. So, it seems that sometimes it is a good thing to take it once a day. I will ask my doctor why it wasn't prescribed twice a day though. You've got me curious. I take it for the full 9 months of pregnancy, and because I'm a mutated genetic freak like a previous poster, it helps rather than hurts. Makes my blood more like that of a normal person I guess.
Lovenox is safe during pregnancy and for breastfeeding - the rest are not . . . just another tidbit for the varied population that might need it!
Though in the correct therapeutic range for Coumadin, in the last two weeks I developed a clot in my arm at an IV site, and just returned from an overnight in the hospital for "throwing a clot" and winding up with a number of clots in my lungs. They have prescribed Lovenox for 9 months. This thread of comments has helped me formulate some follow up questions I never would have known to ask.
Reading through all of your comments it makes me very uneasy that my Grandmothers doctor is planning on releasing her from the hospital on Levonox, on what she said would be daily shots for the remainder of her life. She is 93 and has been throwing clots over the last month and had three surgeries. She does not have insurance to pay for medicines so it will be a huge medical exspense for her. Does anyone have any thoughts.
One thing that becomes very obvious in reading this original post is that there is a lot of misinformation in the original post about anticoagulation, enoxaparin in particular.
It is indicated for inpatient treatment of DVT 1.5 mg/Kg Q24H. Many physicians use that as an outpatient as well (although not FDA approved).
It is indicated for medical prophylaxis and for THR at 40 mg Q24H.
Duration for therapy is generally 5 days for treatment...7-10 days for prophylaxis, but in cases like an oncology patient, the guidelines state that you should continue proplylaxis for as long as the risk (cancer in this case) is there. There are several other studies looking at longer durations of therapy.
The incidence of HIT is significantly less than that of UFH (see NEJM Warkentin article), although it can happen with LMWHs, like enoxaparin.
Additionally, there are a variety of settings where switching someone to warfarin therapy is just not a good idea. Cancer patients, for example, typically have a high rate of recurrence on warfarin and therefore, that has led to studies looking at enoxaparin and dalteparin in that setting.
Another setting is pregnancy, where warfarin is contrindicated in most cases. Heparin or LMWH is generally chosen. LMWH is advantageous b/c of once daily dosing.
I could go on.......
i have a few curiosities myself concerning all the info about anti-coagulating drugs, would appreciate any info. wld_chld76@yahoo.com I have a blood disorder called antiphospholipid syndrome, and the doctors pound it after bi-lateral pe need all help i can get along with info about drug companies who would help i am 31 and dont feel i am ready to die because i cant afford these meds.
Angry Pharmacist,
You obviously know very little about the pharmacology or approved indications for lovenox. The half-life of lovenox is 4.5 hours. It is appropriate to dose it at 40 mg. QD for VTE prophylaxis in THA (total hip arthroplasty), abdominal surgery and acutely ill medical patients. This has been tested in numerous clinical trials and shown to be at least as effective as coumadin therepy post THA surgery. This use is for prophylaxis, not DVT treatment. The half-life is important when treating a DVT or PE, not when used for DVT prophylaxis. The labeled indication for lovenox in THA is 7 to 10 days inpatient given 40 mg. QD and 21 days post-discharge given 40 mg. QD. Please have your information correct the next time you rant against an MD. As far as the cost and insurance reimbursement, since this is an indicated use for lovenox most plans will pay for it under some structure. Worst case, the physician/hospital will have to call and prior authorize the prescription. The overall cost of one month of lovenox given 40 mg. QD and the cost of coumadin with weekly blood draws for INR testing comes out about equal in most parts of the country. Please try to remember this when a patient has extended outpatient use for lovenox.
I like people who don't follow the status quo and find the truth in all settings, usually the truth lies somewhere between the left and right...thank you angry pharmacist for pointing out that not all doctors are right...thank you to the patients who need to take lovenox for extended periods of time as they are "Zebras" like me and their cases are "different." There needs to be better medicine for those of us who need anti-coagulant therapy as the current medicine is simply AWFUL...until then we need to continue to ask questions and get the help we need without being treated poorly...
I suppose the only question I have is...what do you do for a patient who is not supposed to take Lovenox for an extended period of time but who's body is simply antagonistic to Coumadin? I was told 3-6 months on Coumadin for a clot that I threw in my right lung and a shower of clots bilaterally...but due to a history of several cancers they may keep me on it longer...I tell you what, if my mutations come back normal for blood clotting they can kiss their extension of these meds goodbye...I heard that sunshine helps Coumadin to work better...I will be sitting outside more often...Good luck to everyone on these dreaded meds...keep smiling...even on the hardest days it seems laughter still helps...
Ihave been on Lovenox for 3 years this month, I have about 15 clots through my chest and abdomen about half of which I got while in the theuraputic range on coumadin. I have antiphospholid syndrome and also have hyperhomocystenemia(a genetic problem that causes clotting) I also have another rare disease called retroperitoneal fibrosis. I have had absolutely no problems in the 3 years I have been on Lovenox and probably would have dies without it. So no matter what the standard treatment is some of us have to do what we have to do!
Theresa
I had Loevnox in the hospital every 12 hrs, then was put on Coumadin and continured the Lovenox for the 5 days I was in the hospital and went home on Coumadin. i had pulmonary embolisms in both lungs, probably from a lot of fyling.
I believe we need more considerate, compassionate pharmacist as you. You are right on with the treatment of Lovenox, the first four letters are LOVE, which is what I think you are. Mahalo Nui Loa for your compassione.
Thank you for the comic relief which provided a break in the clouds that rolled in a few weeks ago when I began injecting myself with Lovenox for a high risk pregnancy. It makes me depressed and sick as a dog - they're switching me to Heparin. After reading your post, I don't feel better about blood thinners, but at least it gave me a needed break from my misery. Thanks!
sitting in the hospital while posting this- on L and C- coming off a massive PE 4 years ago and a knee replacement less than a year ago- when my leg swelled up to twice its' size I was admitted and now may have to be on C the rest of my life?- the belly shots and cost of L are a pain but- does anyone think it would be a better alternative than C