Heparin and Lovenox together

[agldragonRN]

have you seen or given heparin and lovenox together?

i was working my prn gig the other day and saw an order for heparin 5000 units (1 ml) sub-q q 8 hours that was started last month for dvt and patient had doppler done again last week (+ dvt) so the md ordered lovenox 80 mg sub-q q 12 hours for dvt.

i called pharmacist for advise and was told it should not "really" be given together but the doctor ordered it so they sent it anyway.

i never seen both given together so i was a little concerned.

[wooh, BSN, RN]

I'm not sure, but I've heard lovenox is easier to adjust dosing on. Perhaps MD wanted to switch from the heparin to the Lovenox and just didn't d/c the heparin? Did anyone call the MD to ask for a rationale for giving both?

[LouisVRN, RN]

That's something I would definitely be calling the doctor for clarification on. I've seen lovenox and heparin for dvts but never together.

[agldragonRN]

perhaps md wanted to switch from the heparin to the lovenox and just didn't d/c the heparin? did anyone call the md to ask for a rationale for giving both?

that's what i thought too. i looked at the charting and did not see anything that mentioned informing md that patient is already on heparin. i called md and she did not call back. i asked the supervisor and she was looking at me like why i was asking. i called the nurse at home who got the telephone order and asked her if she mentioned to the md that patient is already on heparin and she told me yes. she did not chart this that is why i was uneasy. i only work in this place like once or twice a month so i am not familiar with things there.

and the pharmacist was no help either. she was like "well, i was not the one who processed it..."

i don't like to tell anybody how to chart unless they ask me but this nurse just charted something in the line of "+ dvt, informed md and got new t.o for lovenox 80 mg sub-q q 12 hrs". if it were me, i would chart more and say something like "informed dr. smith of + dvt in left popliteal vein and informed md that patient is currently on heparin 5000 units sub-q q 8 hours for dvt. received t.o. to add lovenox 80 mg sub-q q 12 hours dx: dvt" but that is just me protecting my butt. but before i do this i would call my supervisor and pharmacist for advise.

[talaxandra]

They act on different stages in the coagulation cascade so you're unlikely to get unexplected bleeding but it's unnecessary, increases expense and means the patient gets more injections for no good outcome.

[VickyRN, MSN, DNP, RN]

They should not be used together. The patient may have uncontrolled bleeding and die as a result.

Heparin products (21)

Problem: We continue to learn of fatalities from concomitant use of low molecular weight heparin (LMWH) and unfractionated heparin and other anticoagulants. A patient died after receiving LOVENOX (enoxaparin) 66 mg subcutaneously, three times in 20 hours, along with heparin 10,000 units and PLAVIX (clopidogrel) 300 mg.

Recommendation: Be sure that computer alerts for duplicate therapy are fully functional for all heparin products. Use protocols, guidelines and standard order forms to assure that current and recent drug therapy is considered before ordering, dispensing, and administering heparin products. Keep in mind that communication of drug therapy administered in the emergency department or cardiac catheterization lab may not be standardized and may not appear on the patient's drug therapy profile, especially if it was a one-time dose.

http://www.ismp.org/newsletters/acutecare/articles/a1q02action.asp

Duplicate therapy in particular can raise the risk for major bleeds in a patient receiving anticoagulation therapy. Mr. Fricker cited the "classic" example of a person being treated in the emergency department (ED) with a low-molecular-weight heparin (LMWH) and then admitted to the hospital and a continuous heparin infusion is prescribed as part of the admission orders. "The pharmacy may not know what was given" before the patient was admitted, Mr. Fricker said.

http://www.pharmacypracticenews.com/ViewArticle.aspx?d=Operations%2B%26amp%3B%2BManagement&d_id=53&i=November%2B2007&i_id=343&a_id=9550&ses=ogst

The evidence clearly shows that concomitant administration of UFH and Lovenox (LMWH) puts a patient at increased risk for bleeding.

It is important to note that heparin primarily inhibits Xa and IIa about equally, whereas Lovenox inhibits Xa three times more potently than it affects IIa. Therefore, using both anticoagulants increases the risk for bleeding. Checking the aPTT in 6 hours will reveal the therapeutic response to heparin, but Lovenox should have no effect on aPTT. The only clinical tool available to assess the therapeutic efficacy of Lovenox is to monitor anti-Xa levels. Unfortunately, most hospitals do not have the ability to monitor anti-Xa levels at their fingertips.

We strongly feel that unless there is hard clinical data that support not waiting "any time at all," one is putting their patients at risk for developing a bleed. It is important to note that ISMP has numerous reports of patients receiving UFH and LMWH concomitantly who have exsanguinated.

https://www.factsandcomparisons.com/assets/hospitalpharm/oct2001_fix.pdf

[Tait, MSN, RN]

that's what i thought too. i looked at the charting and did not see anything that mentioned informing md that patient is already on heparin. i called md and she did not call back. i asked the supervisor and she was looking at me like why i was asking. i called the nurse at home who got the telephone order and asked her if she mentioned to the md that patient is already on heparin and she told me yes. she did not chart this that is why i was uneasy. i only work in this place like once or twice a month so i am not familiar with things there.

and the pharmacist was no help either. she was like "well, i was not the one who processed it..."

i don't like to tell anybody how to chart unless they ask me but this nurse just charted something in the line of "+ dvt, informed md and got new t.o for lovenox 80 mg sub-q q 12 hrs". if it were me, i would chart more and say something like "informed dr. smith of + dvt in left popliteal vein and informed md that patient is currently on heparin 5000 units sub-q q 8 hours for dvt. received t.o. to add lovenox 80 mg sub-q q 12 hours dx: dvt" but that is just me protecting my butt. but before i do this i would call my supervisor and pharmacist for advise.

1st i give you kudos for investigating this situation.

2nd i think your pharmacist is a tool. to state "i didn't put it in" and to claim it really isn't right but we did it anyway is lazy and unethical. pharmacy should have called the md themselves to ascertain the intended course of treatment.

3rd perhaps the previous nurse is lying to cover her butt. "oh yeah i called and she said it was fine" she charted she got the order but there is no verification that she clarified the heparin. if the patient bleeds out and dies she doesn't have a leg to stand on.

4th i would continue to page the heck out of that doc until she called me back, charting every time i paged her, and then if she says "yes it's fine" i would document that too and then go to my supervisor and alert her to the situation.

if it were me i wouldn't give both until i personally heard from the md, but that would require having a supportive pharmacist who could advise you on the best one of the two to give, though i would think the lovenox since it was the newest order.

best of luck with this one.

tait

[nyrn5125]

until I heard from the md I wouldn't give the lovenox, since it is the new med. Also it should be written in MD order as; Lovenox 80mg sq q 12 in addition to heparin 5000 sq q 8. So there is no confusion. Writing in nurses notes is good too, however, pharmacy doesn't read RN notes and a lot of others don't read them either. The pharmacy should be demanding it be written clearly, not just sending it because the doctor ordered it. that is how mistakes happen

[talaxandra]

Thanks Vicky - I stand corrected.

[turnforthenurse, MSN, NP]

1st I give you kudos for investigating this situation.

2nd I think your pharmacist is a tool. To state "I didn't put it in" and to claim it really isn't right but we did it anyway is lazy and unethical. Pharmacy should have called the MD themselves to ascertain the intended course of treatment.

3rd Perhaps the previous nurse is lying to cover her butt. "Oh yeah I called and she said it was fine" She charted she got the order but there is no verification that she clarified the heparin. If the patient bleeds out and dies she doesn't have a leg to stand on.

4th I would continue to page the heck out of that doc until she called me back, charting every time I paged her, and then if she says "yes it's fine" I would document that too and then go to my supervisor and alert her to the situation.

If it were me I wouldn't give both until I personally heard from the MD, but that would require having a supportive pharmacist who could advise you on the best one of the two to give, though I would think the Lovenox since it was the newest order.

Best of luck with this one.

Tait

Absolutely. We have a hospitalist, although VERY nice, who is very hard to get ahold of. I have had to page him 5+ times before. I document each time I page (usually Q20min), "hospitalist paged. awaiting response." If I still do not hear anything, I call my supervisor and I document that, too. In the past my supervisor has physically hunted this hospitalist down to tell him to answer his pages

[Tait, MSN, RN]

Absolutely. We have a hospitalist, although VERY nice, who is very hard to get ahold of. I have had to page him 5+ times before. I document each time I page (usually Q20min), "hospitalist paged. awaiting response." If I still do not hear anything, I call my supervisor and I document that, too. In the past my supervisor has physically hunted this hospitalist down to tell him to answer his pages

Why is it always the super nice ones that are so damn hard to get a hold of? We had a cardiologist who would NEVER return a page on night shift...ever. He was so nice in person but eventually I noticed he kind of disappeared.

[melbae9]

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.