Edoxaban part 2

To recap I am about to change from warfarin to Edoxaban before a hip replacement. The EP and I thought it was good timing as I would be anti coagulated longer as it is a 24 hr drug as opposed to 4 days to get out of the system. But yesterday at my pre op assessment the nurse contacted the surgeon as she didn't know the protocol and he said the anaesthetist had told him to stop the Edoxaban 5 days before! That can't be right surely? I am thinking now to stay on warfarin for a while. Comments?

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  • That is the problem with doctors. They are not always up to speed with "stuff". If you have just had your pre op it sounds a bit late for doing anything unless you have already switched. The only suggestion I have is to ring the AF Association hotline and speak to an advisor there since we aren't qualified although I know what I would do.

  • Unfortunately different hospitals and different anaesthetists and different surgeon have different rules / ideas. Also more heart consultants are up to date with practice and thinking than in other areas. Also more tecent info that after stopping Anticoagulation the risk increases.

    Five days was the old basis for warfarin and was an overkill in almost all cases but again they didn't understand the increased risks of stopping. Also because warfarin degrades or "stops" slowly this causes a has a reservoir effect which I understand is not the case with NOACs. The NOACs that are taken twice a day obviously stop much quicker than those taken once a day because tge half life is much lower

    For me recently when having an angiogram heart registrar said I had to stop warfarin 5 days before but was insistent that I had to inject with clexane to bridge. Last injection pm day before angiogram 8.30 next morning.

    Do research on NICE, AFA, hospital websites and contact AFA patient services. Also see in anaesthetists professional body guidelines. Then you can go back and challenge.

    Also you could contact your EP in parallel with doing your research explaining what they have said and he may be able to get it reversed.

    If all that fails then personally I would insist on bridging before and after. I know this can be done if on warfarin but not sure about situation if on a NOAC.

    Let us know how you get on.

  • Thank you both. I am seeing my GP tomorrow, so lets see if she will change my private Edoxaban prescription to an NHS one. Then if that hurdle is crossed, I will suggest staying on Warfarin before op. Coming off it for 4-5 days before and then immediately restarting with Edoxaban. I think that might solve all problems - hopefully!

  • Still go for the bridging.

  • That sounds exactly right. Starting edoxaban 12-24 hours after last bridging dose.

    Here's the Guys protocols . First the warfarin one for preop warfarin instructions guysandstthomas.nhs.uk/reso... and the noac one for post op As previous sent to you. guysandstthomas.nhs.uk/reso...

  • Peter:

    What reason for stopping Warfarin 5 days prior to your angiogram? Because of possibly causing a 'puncture'?

  • I had my angiogram straight after my first ablation and had been continuously on Warfarin throughout. To be fair if it had been a planned procedure rather than an emergency then there may have been different protocols but I suffered no ill effect.

    Jo

  • The 5 days off is because THR is surgery.

  • Understood was replying to Peter. Hope all goes well with your hip surgery.

    Jo

    x

  • Peter. Why would I need bridging? Do you mean for the 24hrs until it kicks in?

  • I think Peter is trying to explain that you are at risk during the five days you have stopped warfarin. Clexane has a very short life so self injecting for those five days ensures that your risk is covered yet also ensures that your levels are normal when the op is done.

  • So bridge in the pre op days?

  • But surely that means I would be over anti coagulated?

  • I see your point. I think you should speak to someone at AFA and ask them this question I.e. why you would need bridging post op if the NOAC kicks in immediately.

  • NOACs do not quite kick in immediately and some have different response times. They do kick in quicker than warfarin for most people.

    There is a difference as to how a NOAC works v warfarin so ther can be an overlap but local Anticoagulation service (different CCG than my heart hospital) told me that some doctors / Anticoagulation clinics either don't practice it or don't know about it.

    For ME when switching from apixaban to warfarin I started taking warfarin on a Monday evening but continued taking the apixaban twice daily. Then had a blood test on the Friday morning which showed INR at 2.2 so they phoned me Friday afternoon and said not to take the apixaban Friday evening. Effectively I was taking both for 4 to 5 days.

  • This was the heart registrar who I saw who explained (and did it for me) was to stop warfarin 5 days beforehand. Then nothing the next two evenings to allow INR to drop and then two evenings injecting with clexane and then the next day (day before the angiogram) to inject around 2pm.

  • G'day Barb,

    I had a partial knee replacement in early Nov 2015 and was directed to come off Warfarin 1 week before surgery - which I did. Immediately after the big 'carve up' I was injected with Fragmin, a bridging anticoagulant. I might add it took all of that week for my INR to drop to 1. (I have my own INR testing device so this was a non issue for me to keep track of my INR).

    I was in surgery at 11 am ish , up and around mid afternoon but not exactly in 'Strictly ' mode. I had two Fragmin injections in Recovery and then in the evening at my usual evening meds taking time (around 8 pm ish) I resumed Warfarin. No sweat. It took 29 days from when I stopped Warfarin to when I returned to my usual INR level.

    Also, a little over 3 years earlier I had a CT Scan - same procedure for stopping Warfarin, i.e. 1 week before the scan. Also 29 days to return to my usual INR level.

    John

  • Up date. After numerous phone calls my EP has agreed with me that I stay on Warfarin and start Edoxaban after the op but he would not advise on the Warfarin protocol for surgery. The surgeon is on holiday but another surgeon (who doesn't know me) advised that I stop the Warfarin 5 days before with no bridging. Although I am at the moment in SR, I am not too happy about that as I don't think that I am being considered as an individual ie I have had a clot before. But there's nothing more that I can do now.

  • Unfortunately as I was told many are not aware of the revised information and research and updated practices re stopping of anticoagulants. My orthopaedic surgeon wasn't until alerted him and then he said he was going to research this - ie he is open minded.

  • I meant to say thank you all so much for your advice. it has helped.

  • So, I now have an NHS prescription for Edoxaban. GP had never heard of a Patient Alert Card and would not interfere with warfarin protocol even with my history. So, there we are folks. Watch this space. Please God don't let me go back into AF before the 22nd!

    PS. I have hired some super modern ergometric crutches that even have reflectors for night walks!

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