Skip to content
View in the app

A better way to browse. Learn more.
allnurses

A full-screen app on your home screen with push notifications, badges and more.

To install this app on iOS and iPadOS
  1. Tap the Share icon in Safari
  2. Scroll the menu and tap Add to Home Screen.
  3. Tap Add in the top-right corner.
To install this app on Android
  1. Tap the 3-dot menu (⋮) in the top-right corner of the browser.
  2. Tap Add to Home screen or Install app.
  3. Confirm by tapping Install.
Discussion

Warfarin and Lovenox

I'm not overly familiar with coumadin and lovenox, and I'm hoping to get some feedback from more experienced nurses. I recently had a pt who was ordered coumadin 12mg po QHS (Hospital policy is 1700) x 4 days and Lovenox 130mg SQ daily x 3 days. Pt has a hx of DVT, CVA. PT was 11.2 and INR was 1.0. Pt states she has not been taking her medication recently. I understand that the INR is low for a pt on coumadin, and I'm aware of her hx of clots, but is this a safe dose? I rarely give these medications at my facility, and I certainly felt uncomfortable with the dosage combined. I felt like it was a bit excessive. Any thoughts?

  • Quote

    • Featured Replies

    It's not unusual to "bridge" patients onto coumadin using lovenox since it reaches therapeutic levels immediately and doesn't require ongoing monitoring. The coumadin will usually take a few days or more to reach therapeutic levels, so the purpose of the lovenox is is to cover them for anticoagulation until then.

  • Quote
    • Expert

    It depends. Did you get a chance to read the doctors’ notes? She could have been diagnosed with a hypercoagulable state or thrombophilia. You don’t mention her age nor her other conditions, but with a history of DVT and CVA, it is a possibility.

    We are so used to warfarin therapy with a-fib at doses anywhere from 2 mg to 5 mg per day that seeing a patient get 10 mg is frightening. I had two patients in hypercoagulable states where I hesitated to give the very high dosages—12 mg and 15 mg—although their INRs were therapeutic. Reviewing the doctors’ notes shined some light on the dosages: they both had inherited hypercoagulable states. However, I’ve never seen those very high dosages on individuals receiving warfarin for just for a-fib and in the absence of hypercoagulability or thrombophilia.

  • Quote

    I know Lovenox is dosed based on weight. What was the patient's weight?

    Lovenox is used as a bridge until INR is therapeutic.

    I have never given a dose of Coumadin that is higher than 7.5mg however I don't work on a cardiac unit. What was the patient's previous dose? Is this a new drug for them? What does the doctor's note say? I would at least double check with pharmacy about a 12mg dose. Maybe there is a reason for it. Maybe the patient requires that dose to maintain a therapeutic INR. I have also heard of patients INR needing to be higher than the typical 2-3 due to certain conditions (can't remember which - maybe certain artifical heart valves?).

  • Quote

    I've given 9mg warfarin (coumadin) on a regular basis. The standard doses however are around the 2-5mg mark.

    The clexane standard 10-20mg for surgical prophylaxis, given as 1mg per kg to achieve therapeutic INR

  • Quote

    Just like the other comments, Lovenox is given until INR is therapeutic (bridging). Based on your meds' high dosages, I would assume that your patient's weight is on the heavy side. We had 1 patient before with a very heavy weight whose coumadin dose needed to go up to 15mg til the INR finally budged. Some patient on high doses may qualify for an INR monitoring machine for home use.

  • Quote

    Considering they are getting 130 mg of Lovenox, I would take that to mean the pt. is a bigger individual. The dose of Coumadin is relatively high, but I've given higher. Coumadin affects everyone differently and many individuals need fairly high doses to get their INRs up. Giving both is, as mentioned, very common--to use the Lovenox as bridge therapy until the pt's INR is therapeutic.

    Other questions: do they have an artificial heart valve (if so, the pt's target INR will be higher)? Did the doctor write in his/her notes what the target INR is for the pt?

    Regardless, using both drugs at the same time is normal, and the dosage does not seem to be ridiculous.

  • Quote

    They are trying to get the pt therapeutic. There is a ton that goes into dosing of Coumadin. I had times where I was only on 2mg, then something wacky would happen to my body and I could be up to 8-10mg. No matter what, my INR was very rarely stable from one week to the next for various reasons. One time I had an INR of 11.2. Was covered in bruises. Received emergency vit k to reverse the effects, waited several days then started low dose therapy with lovanox. The best day of my life was being taken off that stuff.

  • Quote

    • Join the conversation

    You can post now and register later. If you have an account, sign in now to post with your account.

    Guest
    Add a Comment
    Go to topic listing

    Currently Reading 0

    • No registered users viewing this page.

    Account

    Navigation

    Search

    Search

    Configure browser push notifications
    Chrome (Android)
    1. Tap the lock icon next to the address bar.
    2. Tap Permissions → Notifications.
    3. Adjust your preference.
    Chrome (Desktop)
    1. Click the padlock icon in the address bar.
    2. Select Site settings.
    3. Find Notifications and adjust your preference.