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Re: Coumadin therapy after valve replacement surgry

Posted By CCF CARDIO MD - APS on April 02, 1999 at 12:21:32:

In Reply to: Coumadin therapy after valve replacement surgry posted by dl on March 24, 1999 at 21:58:44:






: : : : : My Husband is needing aortic valve replacment surgery and is very concerned about taking coumadin afterwards. We have a couple of questions. I have read some information about coumadin already and it has promtped these concerns. 1- How restrictive do you have to be with your activity? Is it mostly contact sports that must avoided? 2- Why can't ASA be used as a blood thinner instead of coumdin? My husband has had nose bleeds from being on ASA and vitamin E at the same time. 3- If he wants to continue to take vitamin E after surgery is it allowed? 4- I noticed that there were other drugs that shouldn't be taken with coumadin. Antacids were on the list. Does that mean he can't take an occasional one for GI upset? 5-What if he needs an anti-inflammatory drug? 6-I had heard that someone was making a machine to monitor your PT a home (sort of like the glucometer). Do you know anything about this? Thank-you for your information.
: :



: : : : I will let an MD answer your questions, but my dad has been on Coumadin for 4 years without any problems whatsoever.  In fact, his physician says he's the best patient he's ever had as far as controlling his Pro Time level.  Don't be afraid of the coumadin, just be careful with it.  My dad does anything he wants to, just watches what he eats so he gets no interactions with food.  The physicians on this forum are great, you can listen & believe what they say
:



: Dear Kim:
: I underwent mitral valvoplasty 9 years back.  Eversince, I am on 'warfarin'.  My surgeon did not specify
: : : any restriction on diet or outdoor sports etc. except putting on weight beyond 72-73 Kgs.  He also
: : : advised to check my PT levels once in a while and adjust the dosage accordingly.  I am perfectly fine
: : : got married 2 years back and my wife is in the family way.  So best of luck to your husband, he is going
: : : to be fine.
: Subbaraman.R
_____
: :   _


: : : : Dear Kim
     I had a mitral valve repair in September 1998 and have been on coumadin for 6 months.  This forum has provided a post of drug interactions and the problem with coumadin is that it reacts with hundreds of drugs and some of them increase its effects and some decrease it effects. It is worth looking at the older posts to get that information and understand it.
     You job as patient is to monitor your INR or protime levels.  If they are too low, it could cause a clot.  If they are too high you could have bleeding.  It takes some time (it varies from person to person) to get to the stable dose.  I did take vitamin e (which tends to increase its effects).  Most physicians tell you to maintain a consistent eating pattern.  Remember that your blood at theraputic levels will take from about two to three and a half times normal to clot.  Some common sense is a good idea.  
     The hospital and/or physician will provide you with some guidance including booklets about taking coumadin.  I recommend that you carefully read them and understand them.
     I engaged in physical activities while on coumadin but carefully.  For example, if I ride a bicycle, I always wear a helmet.  Most physicians do not recommend skiing but I did ski and again wore a helmet.  The major concern is an internal hemorage that could be very serious.  Common sense is important to prevent any kind of trauma to the body or head.  Always wear a seat belt and keep an information card indicating the use of coumadin.
   There are some unusual thinkg to be careful of.  Green tea for example.  I stayed away from all health food herbs such as ginsing etc.  Their effects have generally not been studied but there are cases of spontonuous bleeding of some people who took certain types of of chineese herbs.  I would be extra cautuous about taking any health food supplements while on coumadin.
     Be careful of the over the count pain relievers such as advil, Tylanol and asprin.  I did take them but only for very limited periods of time i.e. one dose.

: : Best of Luch  




: Dear Nathan,
: WOW- what excellent advice you give to KIM, Thank you for this and for sharing
: with us all on the heart forum.




I am very interested in this conversation, as my mother (64yrs) needs to decide between pig and plastic valves. In particular I am interested in whether the newest generation of pig valves last over the commonly quoted life of 10 yrs. And what are the risks of  taking warfarin.
Regards john




with regard to the mentioned herbal items and its compatability with coumadin???? how do you begin to know what will interact w/coumadin, a pharmacist? it seems everyone is taking these herbals and having some success with less stress etc, would it be okay with being on the coumadin??





Be very careful about using any type of herbal remedies while on coumadin.  Many of these can interact.  If you are unsure check with your doctor or pharmacist. Common foods such as grapefruit juice, leafy green vegetables and many drugs can also change coumadin levels.  Smoking also changes drug levels.
The following is information on warfarin and it's drug interactions.  
Coumadin (generic name Warfarin) is a anticoagulant (blood thinner) that is used for a variety of conditions.  Common reasons for coumadin use are in atrial fibrillation to reduce the risk of stroke, in persons with clotting disorders, in persons with mechanical heart valves, and sometimes in people with severe heart failure.  The usual dosage is somewhere between 1 and 15 mg a day.  Potential side effects include bleeding, hair loss, nausea, vomiting, stomach cramps, diarrhea and leukopenia (low blood cell count).  The half life (amount of time for half the drug to be cleared from the body is 42 hours but varies widely depending on the individual).  
Many drugs interact with coumadin and may cause more anticoagulation effect (clofibrate, diazoxide, ethacrynic acid, nalidixic acid, phenylbutazone, salicylates, aspirin, sulfonamides, alcohol, allopurinol, amiodarone, cimetidind, phenytoin, erythromycin, gemfibrozil, propranolol, thyroid drugs) or decreased anticoagulation effect (smoking, estrogens, vitamin K, aluminum hydroxide - antiacids, cholestipol, spironolactone).  See complete list below.  The effects of coumadin must be carefully monitored by a blood test called an INR.  Usually this is checked more often at the onset of taking the drug and less often once a steady state has been reached.  Therapeutic INR is usually 2 to 3 depending on the condition being treated.
Pregnant women and those with a hypersensitivity to coumadin should not take this medication.  
The medication should not be taken with food and any signs of bleeding should be reported to your doctor.  Use a soft toothbrush, avoid hazardous activities, carry Medi-Alert ID identifying drug useage and notify your doctor if you have any dark brown urine or red or tarry black stools.
Known Drug interactions with Warfarin
Increased Effect :
                       Highly Probable
                            Alcohol (if concomitant liver disease)
                            Amiodarone
                            Cimetadine
                            Clofibrate
                            Cotrimoxazole
                            Erythromycin
                            Fluconazole
                            Isoniazid
                            Metronidazole
                            Miconazole
                            Omeprazole
                            Phenylbutazone
                            Piroxicam
                            Propafenone
                            Propanolol
                            Sulfinpyrazone
                       Probable
                            Acetaminophen (Tylenol)
                            Anabolic steroids
                            Aspirin
                            Chloral Hydrate
                            Ciprofloxacin
                            Dextropropoxyphene
                            Disulriam
                            Quinidine
                            Phenytoin (Dilantin)
                            Simvastatin
                            Tamoxifen
                            Tetracycline
                            Influenza vaccine
                       Possible
                            Disopyramide
                            5-Fluorouracil
                            Ifosphamide
                            Lovastatin
                            Metolazone
                            Nalidixic Acid
                            Norfloxacin
                            Ofloxacin
                            Topical salicylates
                            Sulindac
                            Tometin
                       Doubtful
                            Cefamandole
                            Cefazolin
                            Gemfibrozil
                            Heparin
                            Indomethacin
                            Sulfisoxazole
Decreased Effect
                        
                       Highly Probably
                            Barbiturates
                            Carbamazepine
                            Chlorodiazepoxide
                            Cholestyramine
                            Griseofulvin
                            Nafcillin
                            Rifampin
                            Sucralfate
                       Probable
                            Dicloxacillin
                       Possible
                            Azathioprine
                            Cyclosporine
                            Etrelinate
                            Trazodone

No Effect
                    
                       Highly Probable
                            Alcohol (if no liver disease)
                            Antacids
                            Atenolol
                            Bumetanide
                            Diflunisal
                            Enoxacin
                            Famotidine
                            Felodipine
                            Fluoxetine
                            Ketorolac
                            Metoprolol
                            Moricizine
                            Naproxen
                            Nitrazepam
                            Nizatidine
                            Psyllium
                            Ranitidine
                       Probable
                            Ibuprofen
                            Ketoconazole
                            Ketoprofen
                       Doubtful
                            Diltiazem
                            Tobacco
                            Vancomycin

Other Web Sites:
http://search.excite.com/search.gw?c=web&s=coumadin+or+warfarin&showSummary=false&start=20&perPage=20&prev=Previous+Results
Package insert and patient information:
http://www.dupontmerck.com/coumadin/cnsmindx.htm
Food interactions with coumadin:
http://www.rncentral.com/library/health/warfarin.html
Patient information and links:
http://www.hsforum.com/HeartSurgery/TLC/Coumadin/Coumadin.hsf
Home testing
http://www.boehringer-mannheim.com/rapid/coagulation/Coag_EN.html
I hope you find this information useful.  Information provided in the heart forum is for general purposes only.  Only your physician can provide specific diagnoses and therapies.  Please feel free to write back with additional questions.
If you would like to make an appointment at the Cleveland Clinic Heart Center, please call 1-800-CCF-CARE or inquire online by using the Heart Center website at www.ccf.org/heartcenter.  The Heart Center website contains a directory of the cardiology staff that can be used to select the physician best suited to address your cardiac problem.


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