Heparin and Lovenox together

Tait, MSN, RN · Oct 26, 2011

I work in a Pediatric CICU. We use heparin and lovenox together routinely. Lovenox can take several doses to reach therapeutic levels. Therefore, when someone has a known clot, giving heparin until the lovenox kicks in keeps the patient anti-coagulated. I've even sent kids home on coumadin and lovenox together. Sometimes the benefits simply outweigh the risks. It certainly wouldn't hurt to clarify though and make sure D/C'ing the heparin wasn't an oversight.

Coumadin and Lovenox I have seen plenty of times, also heparin drips and coumadin until the INR is therapeutic. Heparin and Lovenox not so much. And if this was the case and the doc wanted to use the heparin until the lovenox was active there would need to be a parameter. At minimum a blood draw and limited amount of double doses in my opinion.

nurseprnRN, BSN, RN · Oct 26, 2011

warfarin (coumadin) and the heparin family (heparin, enoxaparin) work on totally different parts of the clotting cascade. it is perfectly appropriate to maintain a patient on a heparin (checking ptts, partial thromboplastin times, for therapeutic effect) at the same time as oral warfarin (checking pro times, prothrombin times). because they work on different parts of the clotting cascade, their effects are not additive. that is, unlike taking more than one member of the heparin family at the same time, taking warfarin and a heparin together does not increase your risk of serious bleeding.

they do it this way because the heparin family works fast and doesn't require much in the way of dose changes to reach a therapeutic range. it's harder to regulate warfarin, but as soon as they determine the dose to make the pro time perfect, the heparin/enoxaparin can be discontinued. there's no need to taper it because, well, adequately anticoagulated is adequately anticoagulated, no matter what part of the clotting cascade is being messed with.

i completely agree with the posters who say that the nurse must get this order clarified with the ordering md (or coverage) before ever giving both heparins-- one must be discontinued. the risks are listed in the product inserts, and you are responsible for knowing it. just because a physician ordered something neither makes it right nor absolves the nurse of responsibility for giving medications in a safe manner.

agldragonRN · Oct 26, 2011

the lovenox was already given for 3 days when i was working there the other night. i was not the first dose. i worked 7pm-7am and lovenox was timed 12am and 12pm and the heparin 6am, 2pm, and 10pm.

i gave heparin at 10pm and did not realize the lovenox order until 11:30pm. i still called the md anyway. i also told the acting supervisor and called the nurse at home who got the original order. i so wanted to not give the 12am dose of lovenox but i need an md order to hold it. i wanted to call the don but hesitated because she burned me before for doing the right thing. i was out of option so when the nurse who got the order for lovenox told me that she did mention to the md that patient is already on heparin, with hesitation i gave the 12am dose of lovenox. if i were the first dose for lovenox, i would have been calling and calling the doctor and hold the lovenox until i get through.

the weird part was i must have conferred with 4-5 other nurses on the floor including the supervisor and they all thought i was crazy for questioning the order. one nurse even said "they always give 2 anticoagulation meds like heparin and coumadin all the time". i was like okay.

i don't want to work there any more because of how they do things so i am thinking of not giving them any of my available dates any longer.

lrobinson5 · Oct 27, 2011

I'm in school now and have wondered about a situation such as this. Say you did clarify with the MD about giving them both at the same time, are you still supposed to hold the medication? I know they always say that "because the Dr. ordered it" does not excuse a Med error, but in this case you called again and discussed it with the doctor.

Also, say you hold any medication (in this case the lovenox) because you felt it was unsafe. If you turned out to be wrong, would you be in trouble? I've heard from a lot of nurses that the outcome of the error usually decides the punishment.

I've been wondering about this for some time, and reading this post reminded me to ask. Thanks!

nurseprnRN, BSN, RN · Oct 27, 2011

"the weird part was i must have conferred with 4-5 other nurses on the floor including the supervisor and they all thought i was crazy for questioning the order. one nurse even said "they always give 2 anticoagulation meds like heparin and coumadin all the time". i was like okay."

this is because they have no idea what the mechanism of action is for either, and they don't understand the rationale for why warfarin and a heparin are given concurrently-- the heparin is for immediate, in-hospital use when anticoagulation is needed now, and the coumadin takes time to determine the patient's optimal dose and is used outpatient after things are stable. that's why i explained it above. suggest you let them know. this is scary ignorance.

nyrn5125 · Oct 27, 2011

"the weird part was i must have conferred with 4-5 other nurses on the floor including the supervisor and they all thought i was crazy for questioning the order. one nurse even said "they always give 2 anticoagulation meds like heparin and coumadin all the time". i was like okay."

the 2 anticoagulants they give are not 2 heparins. heparin is to cover the pt while the coumadin would be taking effect to be at a therapeutic level which can take many days to get adjusted. the 2nd anticoagulant was not coumadin, it was lovenox. in my hospital when we have a positive pulmonary embolus on ct we start either iv or sq heparin or lovenox, but not both. the idea that 4-5 other nurses think questioning a doctor is wrong is crazy.

Tait, MSN, RN · Oct 27, 2011

Sounds like you might have uncovered a hornets nets. Be careful