Lovenox as a sub for Coumadin - dizzy/lightheaded?

[Unregistered]

Hello

My Dad, a coumadin taker for 20 years due to a mechanical valve, was supposed to have surgery on Nov 8. This surgery necessitated him to be off Coumadin for 10 days.

Nov 4 (Friday a week ago) they realized he has an atrial flutter. Surgery canxed. He HAS to have this surgery, but they have to sort out the heart issues.

For whatever reason, the cardio is dragging his feet to actually see him - "appt time slots are full". They were going to have him come in on Nov 30 (!!) to find out why he has this atrial flutter. The regular doctor raised cain about it, and the cardio finally relented and put Dad in for Nov 18 (one week from now). Note that Nov 18 is two weeks after they found this atrial flutter.

Meanwhile, my Dad has now been off coumadin for two weeks. And another week yet for just the cardio appt. And this means the surgery will be pushed out to [date TBD]. Because he has to be off coumadin a total of ten days before surgery, putting him back on coumadin now means it is going to screw up the timing on his mandatory surgery.

Not to mention I think he will need to take Lovenox with the coumadin for a while before the coumadin starts to work effectively again. Meanwhile, the Lovenox shots are 70 bucks a day out of pocket. 70 x 30 = 2100 bucks if it takes that long.

The point of all this: ever since coming off the coumadin he's had bouts of lightheadedness and dizziness. Last night he was scared. He's communicated these symptoms to his regular doctor, and I think (but am not sure) the cardio when they were raising cain about moving the dates around. What does Coumadin do that Lovenox does not?

Thoughts?

 

[bbchien]

Coumadin actually measurably "thins the blood" and prolongs the "template scratch" bleeding time. Lovenox used properly does not.

Welcome to the shortages induced by Mr. Obama's nightmare care. It's like bread in soviet russia: Lower the price and the shelves are bare. It never works.

 

[AcroBoy]

Both coumadin and lovenox inhibit blood clotting, but by different mechanisms. Coumadin can take a few days or longer for your liver to start making the clotting enzymes again, while the actions of Lovenox will usually be gone within around 12 hours, so it is easier to stop prior to surgery. It is extremely expensive, but does not require monitoring via blood tests. Then, there's the need to give yourself a shot.

Light headedness would not be a common side effect of any of the heparins like Lovenox, but rather his heart valve may be worsening, or his A-fib or A-flutter may mean he's not maintaining enough blood pressure to perfuse his head.

You need to make sure his doc and the cardiologist knows he's having symptoms.

 

[JesseD]

Coumadin actually measurably "thins the blood" and prolongs the "template scratch" bleeding time. Lovenox used properly does not.

Welcome to the shortages induced by Mr. Obama's nightmare care. It's like bread in soviet russia: Lower the price and the shelves are bare. It never works.

Really? My friend is a regular MD / Admin and things have been going downhill on some drug supplies for a decade now. I was complaining to him (jokingly) because one of my meds was in short supply after I had my bike accident. He said many drugs had been habitually running short for years, well before the 2008 primaries or even the 2004 elections. I think he said something like 2001/2002, but it's been 5 years since we were joking about it.

 

[Gary F]

Hello
. They were going to have him come in on Nov 30 (!!) to find out why he has this atrial flutter. The regular doctor raised cain about it, and the cardio finally relented and put Dad in for Nov 18 (one week from now). Note that Nov 18 is two weeks after they found this atrial flutter.

Meanwhile, my Dad has now been off coumadin for two weeks. And another week yet for just the cardio appt. And this means the surgery will be pushed out to [date TBD]. Because he has to be off coumadin a total of ten days before surgery, putting him back on coumadin now means it is going to screw up the timing on his mandatory surgery.

Not to mention I think he will need to take Lovenox with the coumadin for a while before the coumadin starts to work effectively again. Meanwhile, the Lovenox shots are 70 bucks a day out of pocket. 70 x 30 = 2100 bucks if it takes that long.

The point of all this: ever since coming off the coumadin he's had bouts of lightheadedness and dizziness. Last night he was scared. He's communicated these symptoms to his regular doctor, and I think (but am not sure) the cardio when they were raising cain about moving the dates around. What does Coumadin do that Lovenox does not?

Thoughts?

Lovenox is used to temporarily thin the blood while Coumadin wears off which usually takes only 4 or 5 days but would need to be continued until surgery and restarted after surgery until the Coumadin is back in the therapeutic range for a couple of days. Most surgeons around here stop the Coumadin about 5 to 7 days before surgery.

The dizziness can be from a variety of reasons but atrial flutter would be near the top of the list if the heart rate is not properly controlled, too slow or too fast. Has anybody checked his heart rate and blood pressure when he is dizzy? If you want a prompt Cardiology evaluation move up here. It rarely takes more than a week (usually only a few days) to get someone seen for this type of problem.

 

[mikea]

Coumadin actually measurably "thins the blood" and prolongs the "template scratch" bleeding time. Lovenox used properly does not.

Welcome to the shortages induced by Mr. Obama's nightmare care. It's like bread in soviet russia: Lower the price and the shelves are bare. It never works.

Huh? WHAT in the Healthcare reform had any effect on drug prices? PHARMA got a better sweetheart deal then they did with Medicare Part D.

 

[Gary F]

Really? My friend is a regular MD / Admin and things have been going downhill on some drug supplies for a decade now. I was complaining to him (jokingly) because one of my meds was in short supply after I had my bike accident. He said many drugs had been habitually running short for years, well before the 2008 primaries or even the 2004 elections. I think he said something like 2001/2002, but it's been 5 years since we were joking about it.

Decade my ass. We have had multiple shortages of various hospital meds over the past couple of years. We are currently out of fentanyl and IV benadryl and a few other drugs. The problem is getting worse.

 

[Doggtyred]

The point of all this: ever since coming off the coumadin he's had bouts of lightheadedness and dizziness. Last night he was scared. He's communicated these symptoms to his regular doctor, and I think (but am not sure) the cardio when they were raising cain about moving the dates around. What does Coumadin do that Lovenox does not?

Thoughts?

Something to think about.. its very likely the Atrial Fibrillation that is causing his symptoms.

On average, your ventricles fill passively about 70% of their stroke volume... then right before they contract, the atria contract first, shoving an additional 30% into the ventricles... This "Atrial kick" is over 1/4 of your hearts output in the volume it pumps.. measured in liters (a little over a quart) a minute.

So you go from having 100% of YOUR normal cardiac output, then a-fib happens and you're now running at 70%. Thats significant. Decreased cardiac output can cause many things, including dizziness and lightheadedness.

And the faster the heart pumps the less time available to fill, so there may be less blood in the chamber when it contracts, which can lower your cardiac output even further (or not increase it as much as expected when both chambers are functioning).

Its not uncommon for atrial fib to have a faster heart rate, due to the particulars of the condition (unless the rate is controlled with other meds).


Hope the cardiologist sees him and sorts this out soon. If he passes out or feels like he's going to, it could be very appropriate to incur an ER visit and have the cardiologist see him in the hospital (typically whoever is on call has to see the patient within 24 hours of admission).

 

[Doggtyred]

Decade my ass. We have had multiple shortages of various hospital meds over the past couple of years. We are currently out of fentanyl and IV benadryl and a few other drugs. The problem is getting worse.

Its been happening for a long time, but its been more pronounced and more publicized over the past couple years.

The problem is that there are only a very few large drug companies left making many of the drugs we use now. A quality control problem with a batch will take that producer offline. If they are SOLE producer now due to mergers or economic decisions, guess what.. NO DRUG.

If they decide to no longer make a drug because its no longer profitable for them (even if its life saving for a very small population of people)... it goes offline.. NO DRUG.. Tough **** and welcome to capitalism.

If the feedstock is contaminated for an entire drug (such as porcine heparin that was made from Chinese pork bellies) or formulation.. it drops offline and guess what.. No Drug.

This is not a political problem. This is where one has to consider the benefits of pure capitalism versus the benefits of government involvement and even entry into manufacture in a very select portion of the market..

 

[Gary F]

Something to think about.. its very likely the Atrial Fibrillation that is causing his symptoms.

On average, your ventricles fill passively about 70% of their stroke volume... then right before they contract, the atria contract first, shoving an additional 30% into the ventricles... This "Atrial kick" is over 1/4 of your hearts output in the volume it pumps.. measured in liters (a little over a quart) a minute.

So you go from having 100% of YOUR normal cardiac output, then a-fib happens and you're now running at 70%. Thats significant. Decreased cardiac output can cause many things, including dizziness and lightheadedness.

And the faster the heart pumps the less time available to fill, so there may be less blood in the chamber when it contracts, which can lower your cardiac output even further (or not increase it as much as expected when both chambers are functioning).

Its not uncommon for atrial fib to have a faster heart rate, due to the particulars of the condition (unless the rate is controlled with other meds).


Hope the cardiologist sees him and sorts this out soon. If he passes out or feels like he's going to, it could be very appropriate to incur an ER visit and have the cardiologist see him in the hospital (typically whoever is on call has to see the patient within 24 hours of admission).

The problem is usually rate control which can be difficult manage in Afib/flutter. Filling of the ventricle is usually not as much of an issue unless the person has significant diastolic dysfunction, a really stiff ventricle.

 

[Gary F]

Its been happening for a long time, but its been more pronounced and more publicized over the past couple years.

The problem is that there are only a very few large drug companies left making many of the drugs we use now. A quality control problem with a batch will take that producer offline. If they are SOLE producer now due to mergers or economic decisions, guess what.. NO DRUG.

If they decide to no longer make a drug because its no longer profitable for them (even if its life saving for a very small population of people)... it goes offline.. NO DRUG.. Tough **** and welcome to capitalism.

If the feedstock is contaminated for an entire drug (such as porcine heparin that was made from Chinese pork bellies) or formulation.. it drops offline and guess what.. No Drug.

This is not a political problem. This is where one has to consider the benefits of pure capitalism versus the benefits of government involvement and even entry into manufacture in a very select portion of the market..

More publicized? I'm getting emails from our pharmacy all the time, this was an infrequent event in the past. I have been practicing for about 20 years. Those evil drug companies are obviously the problem. So I suppose the FDA and lawyers are blameless. When it is not profitable to make something, it does not get made. I guess that companies should produce stuff out of the goodness of their collective hearts.

 

[bbchien]

Really? My friend is a regular MD / Admin and things have been going downhill on some drug supplies for a decade now. I was complaining to him (jokingly) because one of my meds was in short supply after I had my bike accident. He said many drugs had been habitually running short for years, well before the 2008 primaries or even the 2004 elections. I think he said something like 2001/2002, but it's been 5 years since we were joking about it.

I wasn't talking about meds. I was talking about doctors...and the long time to the next appointment. Sigh.

We are retiring in droves.

 

[denverpilot]

What's up with all the signs up at shopping places recently... "Need to change your Pharmacy? Come here!"

Something must have happened but I'm not participating in the world of pharma so I just see big banners and wonder which government system or insurance company screwed the pooch... again.

 

[Gary F]

Really? My friend is a regular MD / Admin and things have been going downhill on some drug supplies for a decade now. I was complaining to him (jokingly) because one of my meds was in short supply after I had my bike accident. He said many drugs had been habitually running short for years, well before the 2008 primaries or even the 2004 elections. I think he said something like 2001/2002, but it's been 5 years since we were joking about it.

From a recent email from our hospital administration. I don't remember it ever being this bad.
(I replaced my hospital name with XYZ)

DRUG SHORTAGES
As of October 11, 2011, there were 203 drug shortages listed on ASHP’s Drug Shortage website (http://www.ashp.org/), 54 of which are currently impacting XYZ and are listed below:
 Acetylcysteine inhalation solution
 Amikacin injection
 Aminophylline injection
 Ascorbic acid injection
 Atropine injection
 Bleomycin injection
 Bupivacaine with epinephrine injection
 Butorphanol injection
 Caffeine and sodium benzoate injection
 Calcium chloride injection
 Calcium gluconate injection
 Desmopressin injection
 Diazepam injection
 Digoxin injection
 Diphenhydramine injection
 Fentanyl injection
 Fluorouracil injection
 Fluphenazine decanoate injection
 Glycopyrrolate injection
 Haloperidol decanoate injection
 Hydralazine injection
 Hydroxyzine injection
 Ibuprofen lysine injection
 Kanamycin injection
 Ketorolac injection
 L-cysteine hydrochloride injection
 Lidocaine 2% injection

 

[AcroBoy]

Hospitals may barely break even on Medicare patients, and lose on Medicaid. With proposed state cuts in Medicaid funding, there will be growing numbers of uninsured. Guess who pays for this- those of us with private insurance. Otherwise, the hospitals would no longer be able to stay in business. This is partially why our insurance rates keep going up and up.

The other model of course is a government system, like Medicare for all. At least this would provide health care to all, but again, instead of paying higher insurance premiums, we pay through taxes.

Regardless, we will still end up paying more.

Regarding drug availability, a few years ago there might have been twenty manufacturers of say fentanyl or tobramycin. Now there are only a few, and if they shut down one line to ramp up another, there can be shortages. These are the manufacturers of the generic drugs, where profit margins are so thin it becomes barely viable to stay in business, let alone make a profit. So, any drug coming off a patent can be expected to have a shortage at some time, as there will be fewer manufacturers. This is not politics but simply a free market economy.

 

[denverpilot]

Long-term shortages of any product are a sign it's not a truly a free market. Something is preventing competition from stepping in to fill the orders. I suspect a rather long list of things, actually.

 

[Unregistered]

Thank you everyone, this is very helpful. A few questions based on the above, apologies if you explained and I didn't get it. I'm pretty worried.

1. OK, so this is more likely the flutter causing this. Could the switch from one drug to the other have brought this to the surface? I don't recall him talking about dizzy/lightheaded before this. It's possible he's hyper aware now and would comment about it, unsure.

2. If he was a few hours late on his lovenox dose, could that affect the effectiveness of it, make blood just a little thicker and thus cause this bout? Friday night he really did not feel good. His other bouts were noticeable, this was the worst. (note it happened after office hours). As of yesterday afternoon he hadn't had another one. Does Lovenox HAVE TO be on a strict 12 hour sched?

3. How safe is it for him to be on Lovenox (and off coumadin, more importantly) for what could turn out to be 30 days? I'm sure the drug is "safe", but the switch for that long I mean?

4. How safe is it for the cardio to make him wait yet another week? They diagnosed the flutter one week ago, this adds another week. This comes back to question one - could the switch have caused or exacerbated this? I guess I could understand if the thinking is "well, he probably had this issue for months, what is another week" - but what if that isn't the case and this is new.

5. Cardio appt Nov 18 may well mean surgery AFTER Thanksgiving. This means this whole med setup stays the same until after surgery, any issues? We're looking at a month at this point.

6. Finally, is there any effective way to get this cardio to get him in sooner? To me, this sounds serious. Is it not actually that serious and the cardio isn't worried because of that?

Anyway, thank you again.

 

[Gary F]

1. OK, so this is more likely the flutter causing this. Could the switch from one drug to the other have brought this to the surface? I don't recall him talking about dizzy/lightheaded before this. It's possible he's hyper aware now and would comment about it, unsure.

It is very inadvisable to attempt to diagnose a problem in a forum such as this. The answers here should be considered general information.

Yes meds can make someone dizzy or contribute to this symptom but so can a lot of other problems.

2. If he was a few hours late on his lovenox dose, could that affect the effectiveness of it, make blood just a little thicker and thus cause this bout? Friday night he really did not feel good. His other bouts were noticeable, this was the worst. (note it happened after office hours). As of yesterday afternoon he hadn't had another one. Does Lovenox HAVE TO be on a strict 12 hour sched?

Can't say with certainty but being a few hours late with the Lovenox is usually not a big deal unless you are being treated for a really serious problem like pulmonary embolism or valve thrombosis (clotted heart valve).

3. How safe is it for him to be on Lovenox (and off coumadin, more importantly) for what could turn out to be 30 days? I'm sure the drug is "safe", but the switch for that long I mean?

I would not be entirely comfortable for a patient with a mechanical valve to be off Coumadin (and on Lovenox) for that long but it has been done. It really depends on the type of heart valve and other issues. At my facility this delay would be unusual. Mitral valves are a bigger problem than aortic valves. Here are some papers which are a little dated but contain a lot of useful information.

2 large prospective surveys including a total of 327 patients with prosthetic mechanical heart valves treated with LMWH in this situation have recently been published.6,7 They concluded that a standardized periprocedural LMWH-based anticoagulant regimen is associated with a low risk of thromboembolism and major bleeding complications.http://circ.ahajournals.org/content/113/4/564.full

Conclusions: Enoxaparin may be an effective and relatively safe substitute anticoagulant for patients with mechanical heart valves who must withhold acenocumarol. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1767627/

http://circ.ahajournals.org/content/113/4/470.full

4. How safe is it for the cardio to make him wait yet another week? They diagnosed the flutter one week ago, this adds another week. This comes back to question one - could the switch have caused or exacerbated this? I guess I could understand if the thinking is "well, he probably had this issue for months, what is another week" - but what if that isn't the case and this is new.

Probably low risk as long as he is on Lovenox, see above. It is highly unlikely that the switch from Coumadin to Lovenox had anything to do with his afib/flutter.

5. Cardio appt Nov 18 may well mean surgery AFTER Thanksgiving. This means this whole med setup stays the same until after surgery, any issues? We're looking at a month at this point.

Things are about to get worse, probably a lot worse. The government is proposing large cuts in Medicare and Medicaid. Expect a fair number of older specialists to say **** it and retire early.

6. Finally, is there any effective way to get this cardio to get him in sooner? To me, this sounds serious. Is it not actually that serious and the cardio isn't worried because of that?

Anyway, thank you again.

It sounds like the primary already got the appt moved up so probably not unless something changes but I don't know what is going on with the cardiologists at that hospital. Emergencies like heart attacks come first. Primary docs are sending a lot of patients to be evaluated for a wide variety of reasons, some good and others not so good. One of the more common bad reasons is when somebody with no evidence of a heart problem keeps complaining so the primary sends them to make sure that are not missing something to reduce the risk of getting sued for failure to refer in a timely manner.

 

[Unregistered]

Thank you Gary.

The reason for this appt is because he must have surgery done and they cannot do it without making sure his heart is doing what it is supposed to do. They talked about a pacemaker, but I understand now from Dad (just talked to him) that they won't put anything in on Friday, this is just an appt so the cardio can advise them what to do for this surgery. So this really is pushing back the surgery date if they then have to fit him with something at a different appt. This surgery really shouldn't wait either, but the heart is more important.

It is aortic valve, not mitral. Thank you for the papers.

 

[Gary F]

Thank you Gary.

The reason for this appt is because he must have surgery done and they cannot do it without making sure his heart is doing what it is supposed to do. They talked about a pacemaker, but I understand now from Dad (just talked to him) that they won't put anything in on Friday, this is just an appt so the cardio can advise them what to do for this surgery. So this really is pushing back the surgery date if they then have to fit him with something at a different appt. This surgery really shouldn't wait either, but the heart is more important.

Whuut? We have done elective procedures on nights and weekends. Our group is fee for service so the more you work the more you earn. Our compensation scheme is not based on what type of insurance (if any) a patient has so everybody gets prompt service. If a group of physicians is salaried the rules change a lot. Many specialists are joining hospital practices as employed physicians to avoid the uncertainty of changes in reimbursement. The government wants physicians to be employed as it is easier to control hospitals (and therefore the employed physicians) than individual practicing physicians.

It is aortic valve, not mitral.

That's good.

 

[bbchien]

Unreg, this sting is an example of why I only give CERTIFICATION advice. The rules are clear cut.

You really, really really need to visit with your family doc sooner rather than later. It's inappropriate to be getting a consult on a webboard and it's somewhat risky for the docs to be giving same.

 

[Unregistered]

Unreg, this sting is an example of why I only give CERTIFICATION advice. The rules are clear cut.

You really, really really need to visit with your family doc sooner rather than later. It's inappropriate to be getting a consult on a webboard and it's somewhat risky for the docs to be giving same.

We are trying. I am not convinced this cardio knows his history. I think my Dad needs to write out a timeline for this cardio and send it to him. We just did looked at the calendar, and in fact it may be close to FIVE WEEKS off Coumadin if he cannot see this cardio until Nov 18. I do not know if his surgeon can schedule anything quickly if he doesn't learn about the heart advice until late Friday afternoon which is less than a week before Thanksgiving.

Thanksgiving week is nearly four weeks off Coumadin.

 

[Gary F]

Unreg, this sting is an example of why I only give CERTIFICATION advice. The rules are clear cut.

You really, really really need to visit with your family doc sooner rather than later. It's inappropriate to be getting a consult on a webboard and it's somewhat risky for the docs to be giving same.

As I wrote earlier: It is very inadvisable to attempt to diagnose a problem in a forum such as this. The answers here should be considered general information.

There are several problems when trying to get an answer to a specific medical question. It is impossible to have all of the necessary patient information and a proper physician patient relationship does not exist. Confidentially is non existent on the web. I think that forums can be useful in providing general medical information similar to a "Ask the Doctor" call in television show. We have one in our area and local physicians take turns trying to give cogent responses to caller's often vague medical questions.

 

[Doggtyred]

Thank you everyone, this is very helpful. A few questions based on the above, apologies if you explained and I didn't get it. I'm pretty worried.

1. OK, so this is more likely the flutter causing this. Could the switch from one drug to the other have brought this to the surface? I don't recall him talking about dizzy/lightheaded before this. It's possible he's hyper aware now and would comment about it, unsure. THE DRUG IS PROBABLY NOT THE CAUSE.

2. If he was a few hours late on his lovenox dose, could that affect the effectiveness of it, make blood just a little thicker and thus cause this bout? Friday night he really did not feel good. His other bouts were noticeable, this was the worst. (note it happened after office hous). As of yesterday afternoon he hadn't had another one. Does Lovenox HAVE TO be on a strict 12 hour sched? ESSENTIALLY YES. ANYWHERE FROM 1 HOUR BEFORE TO 1 HOUR AFTER THE SCHEDULED TIME WAS THE STANDARD I WAS HELD TO AS A NURSE.

3. How safe is it for him to be on Lovenox (and off coumadin, more importantly) for what could turn out to be 30 days? I'm sure the drug is "safe", but the switch for that long I mean? THE LOVENOX IS THERE BECAUSE THE COUMADIN ISNT. UNTIL THE COUMADIN IS AT A THERAPEUTIC LEVEL, SOMETHING NEEDS TO PICK UP THE SLACK. COUMADIN TAKES TIME TO WEAR OFF, WHICH IS WHY ITS HELD PRIOR TO SURGERY.

4. How safe is it for the cardio to make him wait yet another week? They diagnosed the flutter one week ago, this adds another week. This comes back to question one - could the switch have caused or exacerbated this? I guess I could understand if the thinking is "well, he probably had this issue for months, what is another week" - but what if that isn't the case and this is new. PEOPLE GO IN AFIB ALL THE TIME.. SOME COME OUT WITHOUT MEDS. SOME NEED MEDS OR INTERVENTION TO COME OUT. SOME LIVE WITH IT FOR LIFE. IM NOT A DOCTOR, AND DONT CLAIM TO BE ONE. I WOULDN'T BE SURPRISED IF THE WORSENING VALVE PROBLEM IS SOMEHOW THE CULPRIT.

5. Cardio appt Nov 18 may well mean surgery AFTER Thanksgiving. This means this whole med setup stays the same until after surgery, any issues? We're looking at a month at this point.

6. Finally, is there any effective way to get this cardio to get him in sooner? To me, this sounds serious. Is it not actually that serious and the cardio isn't worried because of that? IF IT WAS URGENT, I SUSPECT YOUR PHYSICIAN WOULD HAVE DIRECTED YOU TO A HOSPITAL FOR ADMISSION.

Anyway, thank you again.

I agree completely with what Gary F and Bruce have said regarding online consultation and online diagnosis. About the only ADVICE I ever give is "go see your doctor" or "go see your doctor right now".

The rest is meant to be informative. Gary corrected me on an item or two, and given that this is his area of specialty I'd go with his statements. His answers are based on the training and education he's received, as are mine. His training is more specialized and much more in depth on this subject.

It sounds like your questions best be answered by a physician, and if the specialist cant see you, perhaps your primary care guy could give some insight. While you are at it, it would be worth asking why you HAVE to wait for this particular cardiologist instead of being referred elsewhere. There's got to be a reason.

 

[Gary F]

It sounds like your questions best be answered by a physician, and if the specialist cant see you, perhaps your primary care guy could give some insight. While you are at it, it would be worth asking why you HAVE to wait for this particular cardiologist instead of being referred elsewhere. There's got to be a reason.

And it may or may not be a good one. The surgeon or anesthesiologist may require the evaluation by a specialist who has credentials at the hospital where the surgery is to be performed, not unreasonable since the specialist should be available to assist with any cardiac peri-operative problems. Another issue I have seen lately is that some hospitals have been bought out and require primary docs to refer to specialists in their system. Two rural hospitals were purchased by a hospital in another state and some of our former patients were inappropriately told they had to switch to other specialists. Their hospital is a 4 hour drive instead of a 2 hour drive to get to us. They still want to dump the uninsured or problem patients on us. It's getting nasty out there.

 

[AcroBoy]

We see the same at our university practice- a patient shows up in some local hospital ED and they're told their problem is too complicated even if the surgeon hasn't examined the patient or seen the X-rays. Invariably when they show up at our hospital the problem is straight forward but they have no insurance.

This is typically done by the local big hospital system that has bought up practices and owes billions on the construction of empty buildings.

 

[Unregistered]

Again, thanks everyone. I know this isn't definitive. I know he has to see his doctor. I was wondering about the choice of cardio too. Maybe this is the best practice in town. Not sure. I get the sense the cardio doesn't know the whole story because if he did, wouldn't he push it through. I told my Dad he needs to right down a timeline and send it to the doctor, including making sure he knows when this coumadin/lovenox changeover happened, and his lightheadedness. This is not his usual cardio, that guy couldn't see him until Nov 30. Same practice.

Mostly I just want to know if this lengthy time on Lovenox instead of Coumadin is cause for concern. If not, great. It's just that with the holidays, everything will be pushed back because his heart appt is Friday.

 

[bbchien]

It's not the length on lovenox as opposed to coumadin. It's the length of not knowing WTHeck is really going on.

 

[JesseD]

I wasn't talking about meds. I was talking about doctors...and the long time to the next appointment. Sigh.

We are retiring in droves.

Can't say I blame you, the old-time country doc was being killed off for a long time. I remember when doc Gage retired. He literally brought me into the world. (OB/Gyn, family doc, whatever was needed) His last few years weren't pleasant and when we ran into him at the grocery store (I wasn't 18 yet) he was complaining about two things: snotty kids that didn't want to be on-call (like he was for decades) and HMO's. Politely complaining, mind you. I can only imagine it's gotten worse in the two decades since he closed his practice rather than let his name be attached to one of those kids.


Sent from my iPad using Tapatalk

 

[Gary F]

It's not the length on lovenox as opposed to coumadin. It's the length of not knowing WTHeck is really going on.

Most cardiac pre-op evaluations are really an exercise to CYA of the surgeon and anesthesiologist. The initial treatment of atrial flutter or fibrillation can usually be carried out by a primary care physician. Often the primary provider will get the ball rolling with some initial tests like an echo but this can be cost inefficient if the cardiologist really needed a different test. The big problem here is that it should not take so long to get a specialist evaluation unless you live in Canada or some other foreign country.

 

[Unregistered]

OK, some news.

My Dad sent a timeline of events to the cardio and sent a copy to the doc doing the surgery. He voiced his concerns over the lengths of time this was all taking.

He learned that the cardio is only in the office Friday this week (and who knows, maybe only Fridays, every week) but the good news is the surgeon said she will do what it takes to make sure he has surgery before Thanksgiving.

It's not a perfect outcome but at least now we know his surgery won't be postponed yet another week because of all of this. Unless of course the cardio views this appt as merely a consult and doesn't actually treat the flutter until the "next" appt.

 

[weilke]

What's up with all the signs up at shopping places recently... "Need to change your Pharmacy? Come here!"

Something must have happened but I'm not participating in the world of pharma so I just see big banners and wonder which government system or insurance company screwed the pooch... again.

There has been some re-shuffling with pharmacy benefit managers. I have lost track of who bought out whom, but I just got a letter from my health insurance company that it is 'express-scripts or bust'. Before, they used to pay whatever their contracted rate with their PBM was if I went out of network, now I have no out of network benefit whatsoever.

 

[Unregistered]

As you may know, Lovenox (Enoxaparin) went generic this year and costs me about $15 for a month's injections. I am extensively searching the web for a reason why I should switch to coumadin, but I can't find one. Until lately, it was all about 1) cost and 2) people don't like to give themselves shots. On the other hand, if there's a downside to Enoxaparin, I haven't found it yet (and I've been on the stuff for a couple of months). True, my lower belly is sometimes bruised, so don't look there. It is a pain to inject oneself but, on the other hand, I don't have to worry about what I eat, either.

 

[Jr Hampton]

Is there still a need to do monthly INR's for certification ? Currently im on Coumadin SI..

 

[Gary F]

As you may know, Lovenox (Enoxaparin) went generic this year and costs me about $15 for a month's injections. I am extensively searching the web for a reason why I should switch to coumadin, but I can't find one. Until lately, it was all about 1) cost and 2) people don't like to give themselves shots. On the other hand, if there's a downside to Enoxaparin, I haven't found it yet (and I've been on the stuff for a couple of months). True, my lower belly is sometimes bruised, so don't look there. It is a pain to inject oneself but, on the other hand, I don't have to worry about what I eat, either.

There is a chance that you may eventually develop HIT or heparin induced thrombocytopenia. The risk is far lower than if you were taking unfractionated heparin but it still exists and if you get it there are major issues to deal with. It also probably has not been studied for long term use for whatever you are taking it for.

 

[bbchien]

Dislike of self injection and the risk of developing HIT is high enough that the agency doesn't get requests for cetification on lovenox. You would be forging new ground. There is no preturbation of the Prothrombin time if done correctly.

 

[Jr Hampton]

One of these days they will have a good replacement for Coumadin . I have done the shots and do not particularly enojy them as they do cause bruising. OTOH, given a choice to give myself shots and have to deal with the medical board it's almost worth it .