Are you talking about your Lovenox dosage as being too low or too high? The dose they gave you seems to be a maintenance dose, rather than a therapeutic dose, unless you are a very tiny person. (They dose you by weight with Lovenox).

I thought the procedure before surgery was to go off Warfarin 5 or 6 days before, but substitute Lovenox until a day or two before surgery, then go back on the Lovenox for a day or two after while starting up the Warfarin again.

It seems as though you have been off the Warfarin a while, you have just had surgery, and they have not given you more Lovenox until the Warfarin kicks in. I would say it would not hurt to call the doctor on call to clarify and confirm what it is you should be doing from this point on.

Also, Lovenox wears off after 12 hours, which is why it is usually needed twice a day to be therapeutic (although there are exceptions to this sometimes).

So if you had your Lovenox shot more than 12 hours ago, the blood-thinning effects have more than likely already worn off.

If you were concerned about the dose being too high while resuming your Warfarin, it would already be out of your system before starting Warfarin tomorrow.

Sorry, I hit the Add button before finishing.

What I meant to say was:

If you were concerned about the dose being too high while resuming your Warfarin, it would already be out of your system before starting Warfarin tomorrow. But Warfarin takes some days to kick in, which is why you are usually given Lovenox to take at the same time as when you start Warfarin, to cover you during this time before Warfarin kicks in. (Lovenox starts working immediately, and reaches its maximum blood-thinning effectiveness for that dose about 4 hours after injection, wearing off after about 12 hours.)

I am referring to the dose of the Lovenox given in the hospital being so high.

The procedure with surgery is to not have either drug 5 to 6 days prior to surgery, because of the risk of bleeding during surgery. Then the day of surgery Lovenox is given after surgery and the patient resumes their Warfarin the next day after surgery.

So I had the surgery today after being off of Warfarin for 5 to 6 days. I recieved 40 mg of Lovenox in recovery at the hospital and are to resume the Warfarin tomorrow. My personal doctor (who is retiring by this time next year) is in the office Mon, Tues, Wed. The nurse and doctor who are there today do not seem to understand. I do not really care for the other doctor and know I need to find a new one but with the surgery I didn't want o change until after the surgery and we have the INR stable. I was going to call the on call doctor and see what they have to say.

Now I think I am understanding this. The Lovenox shot is basically to jump start things and is given with Warfarin. When I was first diagnoised and admitted I was given Lovenox and later in the evening I was given Warfarin (can't remember the dose right now). The dosage was decreased as my numbers started to rise. By day three I was at 2.5 and the ideal was to try to maintain between 2.0 and 3.0. Unfortunately we were in the midst of finding a dose that works for me while still having my salads/greens 3 to 4 times a week. My surgery date was set about 8 months or so ago and rescheduling would be another 6 to 8 months. So while I am learning I had to stop taking the Warfarin to have the surgery. So now I am sort of restarting again. I do think I need to start looking for a new doctor as I mentioned mine is retiring next year. I am not sure what kind of doctor monitors/treats patients with PE. I am inclined to think specialist over GP because my comfort level tells me they will be up to date with the lastest information - not that my GP is not but it just seems to make since. Let the doctor who specializes in an area do so. Thank you so much for helping me understand.
Jen

Jen, yes, the Lovenox is usually given to immediately thin your blood. You could stay on that instead of Warfarin, and it would achieve the same blood-thinning results as Warfarin. But because it is so expensive, etc., it is usually given to cover you (make sure your blood is thinning), while you take Warfarin, and then it is discontinued when the Warfarin becomes therapeutic.

The 40mg dose you were given is, in general, therapeutic for a 90-lb. person. If you weigh around that, then you reached a therapeutic level with it, but it would wear off after 12 hours. I believe that 40mg is also sometimes given as a DVT/PE preventative dose after surgery, but that's for people who don't actively have a DVT or PE (if I'm understanding it correctly). If you actively have a DVT/PE, then I believe a therapeutic dose (or doses) is usually given.

So I'm concerned that you are actually not being covered enough with blood-thinning medication, given your history. (And while I understand going off the Warfarin 5 or 6 days before surgery, because it can take that long to get out of your system, I don't understand not covering you with Lovenox during that time, then stopping the Lovenox a day or two before to make sure it is out of your system, too. It gives you more protection overall, I think. But I'm not a doctor and that's just what my understanding from having read things.)

As far as a specialist, there isn't really a PE specialist, so it's covered by different types of doctors. My pulmonologist handles my blood thinner, but a hematologist could, too, and sometimes even cardiologists do, too. I love my GP - she is smart and on top of things - but even she defers my blood-thinning stuff (and other blood disorder questions) to the pulmonologist and hematologist.

Good luck, Jen, and please take care. It sounds like you've been through a lot, so I'm sending extra get-well thoughts and hugs your way.

Normally you are on either a heparin drip or receiving LMWH until the INR from the Coumadin reaches therapeutic range (2.0-3.0 - or higher in some cases). If the INR level is not therapeutic, the patient may be kept longer or, now-a-day, placed on Lovenox until the PT/INR is therapeutic. Once therapeutic, the Lovenox is discontinued.

Jen, as far as specialists, a cardiologist is usually involved in prescribing blood thinners for conditions other than PEs (although they can sometimes be involved with PEs if the heart was somehow damaged by the PE).

In general, pulmonologists are the closest thing to a PE specialist because they deal with pulmonary problems. But there isn't any specialist that I know of that concentrates exclusively on PEs and its after-effects.

As a man of 200 lbs., or 91 kg, my emergency therapeutic dose of Lovenox was 100 mg 2x daily. I believe Lovenox to be weight driven like Warfarin. Perhaps someone not known for-sure to have dangerous clots could take a lower weight-proportionate dose.

Whatever dose was selected for you, you can do both Lovenox and Warfarn simultaneously. The reason to bridge with Lovenox is that it takes 3-5 days for Warfarin's INR effect to kick in, and during that time its effect on various liver secretions, some with shorter half lives, actually makes your INR drop lower than normal. Also, if you happened to develop or re-grow clots while off Warfarin, Lovenox assists in arresting that growth and retarding formation of new clots.

I just wanted to thank everyone who responded to my concerns. I did call the doctor on call. I explained everything to her. She knows my doctor, matter of fact they used to practice together years ago and she was my doctor then. (Hopefully she is excepting new patients and participates with my insurance)

So we discussed what took place with the Warfarin, surgery, and Lovenox. She told me take 5 mg of Warfarin tonight and 3.5 mg Fri, Sat, Sun. Friday I am to call the surgeon and see what his feelings are in regards to prescribing Lovenox for me to do at home for the next couple of days while still taking the Warfarin. She said given the nature of my surgery he may or may not decide to have me do the Lovenox. If I experience any chest pains or SOB that is not the normal for me then it's time to take a trip to the ER. I am not to second guess it just go if need be.

I will have my blood tested on Monday and then go from there. I will make an appointment with my current doctor to discuss what's going on and the flip flopping of dose amounts. I will continue to see my current doctor and we can work togehter at finding the proper dose that works for me. But it has become clear to me that I need to change my GP. He will be retiring by this time next year any way so I think the time to look is now a given as it may take some time to get in with a new doctor.

I have learned that all of us are unique with our own particular cause/reason why we are here on this forum. What works for some does not work for all. I got a little confused and have to learn how to keep my self focused on me while still be part of the forum. Again thanks to everyone. I am learning and also have to learn not everything I do learn applies to me.

Jen

Frkrhe, I think I know what you are saying. It sounds like you are concerned that the lovenox dose was too high compared to your warfarin dose. They are 2 different drugs and are dosed differently. 40mg of lovenox actually sounds like a low dose unless you are a really small person. Usually they give you larger than normal doses of warfarin to get your level up quickly and keep you on lovenox every 12 hours until your INR is therapeutic after surgery. Most doctors have you do lovenox before surgery while going off the coumadin too, then stop the lovenox 24 hours before your surgery time. Hope that helps. Are you continuing on lovenox until your INR is checked and in the therapeutic range? You should be to be covered. Blessings, Teri

Jen, I'm glad you were able to reach the doctor on call and get your Warfarin dosage figured out for now. Keep taking care of yourself - learn all you can about this and the meds you are taking, and then filter it, as you say, to your situation. No one knows your body and your situation better than you do. (Sounds simple, but I had to learn the hard way through this to trust myself and what my body was telling me, and not what a doctor or doctors said I "should" be feeling.)

Take care.

What my Doctor and Pulmonologist require of me is to go completely off my Coumadin for 5 days prior to surgery and be on Lovenox shots twice a day up to the night before surgery. The day of surgery I have nothing until after the surgery and then I resume the lovenox shots twice a day and add my coumadin back into the mix until I am once again at a therapeutic level for me. This can be anywhere from 3 days to 2 weeks. I take 10 mg of coumadin one day and then 7.5 mg of Coumadin the next to maintain a INR level of 2.5-3.2. My dosage of Lovenox is 80 mg twice a day. As XLS was saying they give lovenox by your body weight and what they are trying to do weather it is a maintenance dose or a therapeutic dose. The reason they use Lovenox or heparin like this is because it only stays in the body for 12 hours where Coumadin takes a good 3-5 days to get out of your system.
I don't see where it would hurt to call the on call doctor just to check if it is making you uncomfortable in any way. It's always better to be safe than sorry.
Hugs and Good Luck
Ferr

Update: I am learning and at the same time getting conflicting information from the many medical providers I see. I did call call the surgeon's office to see about having Lovenox at home and he said he did not think it was needed and to take my Coumadin/Warfarin on Saturday. Well the doctor on call told me to take it the evening after surgery (which I did). I also explained this to the surgeon. So all is well.

So later in the afternoon/early evening something was bothering me. It didn't seem to be medical per say. I just felt odd/off not normal for me. Yes I just had surgery the day before but it was not even my normal for after surgery. I don't know if it was medical as it didn't seem to be, being overly cautious or what. No real symtoms per say. I told my husband who had no real answers. I even called the ER and they said they could not advise to come or not to come - I was looking for a reason to have things checked out I guess and that was my reason for calling. My husband called a local urgent care place and they said while I could come in blood results tke 3 days. No sense in going there.

I pittered around for a little bit (like 20 minutes) and then I make up my mind to go to the ER. I can't drive of course because of surgery and pain meds. So I decide to throw a few things in a tote bag (just in case), take my meds for the evening and off we go. We stopped off and got some fast food just in case it ended up being a long night. Got to the hospital, checked in, was seen by a doctor within 15 minutes, had blood drawn and went back to the waiting room for about 20 to 30 minutes. I was called again and brought back to a room where I saw a PA (did a urine sample as well). We discussed things, waited on the urine and then she decided to call my surgeons office when my IRN came back at 1.0 so they could have me take Lovenox. The surgeon on call was of the mind set that the current PE or a potential new PE far our weighed any potential bleeding issues and decided to have me do Lovenox. So another doctor (so far I see a doctor, PA, nurse, and now another doctor) comes in and discusses things with me as well. I thought they were going to admit me after I said I did not want to be admitted. Although this was after finding out my IRN was 1.0 so if they insisted I certainly would have complied. However they decide to show me how to give myself the Lovenox. Although they decided to use Arixtra which only requires one injection per day. This was the same thing they used when I was admitted upon first finding the PE. If I could do it myself and was comfortable doing so I could go home. I did it with a practice syringe and did it right so they had me do the actual dose there and all was well. I am also to take my Coumadin/Warfarin as well. My husband was a sweet heart going to get the prescritption today. He went to our pharmacy who did not have it but they called a couple different locations and then went on to call other chain pharamacies until they finally found it after about the fifth pharmacy.

So I will do the Arixttra Saturday and Sunday evening. Have my blood done on Monday and if it is not in the therapeutic range of 2.0 and 3.0 I am to talk to my doctor about more Arixtra which is what the hospital said.

Like I said I have lots to learn. I know we are all different as is our conditions and reasons behind being diagnosied with a PE. One thing I am sure of is I need to be more proactive with my health/this condition. I do thank all of you who shared your stories/experiences with me. I think we learn from one another. I still do not know why I had the feeling that I needed to go to the ER, but I am glad I did.

Thanks,
Jen

Glad to hear you were treated and released with an action plan.

I was on 80 mg of lovenox right after my PE in July. I wound up with complications from the surgery that lead to the PE and my warfarin and lovenox were stopped. When I was stable again, I was switched to 40mg of lovenox.

So I don't know the logic or reasoning behind the dose, but I was on both the 40mg and the 80mg at different times.