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     More and more patients are presenting to the podiatric physician on Coumadin, Plavix, Pradaxa, and Effient. Changing the anti-coagulation regimen must be considered before any surgery or in-office procedures. There is little podiatric literature on when the patient should discontinue the anti-coagulant prior to surgical intervention. Most physicians discontinue Coumadin 3-7 days before surgery and usually under the knowledge of the primary care doctor or cardiologist. Recall that the biological half-life of Coumadin is 36 to 42 hours.
            There is dental literature stating that dentists should also be weary of ceasing Coumadin when tooth extractions and other procedures are necessary. This is relevant as podiatric physicians perform multiple in office procedures. There are documented cases where dentists have told patients to discontinue Coumadin and adverse effects have occurred including thromboembolic events and even death. They did not substitute the Coumadin with another anticoagulant.
Usually, the surgeon will substitute Coumadin (or other anti-coagulant) for Lovenox® for a short duration. Coumadin is ceased 3 days prior to the procedure and a regimen of Lovenox (or heparin) is initiated. They have a shorter half-life and therefore can minimize interruption of anticoagulation via multiple dosing, e.g. a tighter window.  Approximately 8-12 hours prior to the surgery, the Lovenox is stopped, the surgery is performed and the Lovenox is restarted, as well as the coumadin. Once the Coumadin has reached it’s peak in the blood, the Lovenox is discontinued. Blood draws can affirm the therapeutic ranges of Coumadin but newer medicines cannot be closely monitored with blood tests (INR).  It should be noted that Lovenox can only be substituted in some cases, as it is not indicated for atrial fibrillation.
            Typically, patients should not have to stop Coumadin for simple in office procedures such as nail avulsions, punch or shave biopsies, and aspirations. The risk of the patient suffering a thromboembolic event, such as a DVT or PE (deep vein thrombosis or pulmonary embolism) ,outweighs the risk of the patient bleeding more than normal. Simple compression bandaging can be performed in these cases. Surgeries like bunionectomies, hammertoe corrections, and fracture repair, however, require modification of the blood thinner. Each patient and situation is unique and consultation with your doctor is best.  
 1 Smith TF, Zada LS: Continuous Coumadin Anticoagulation, Myth vs. Reality. The Podiatry Institute Update, 2006.
Dr. Laal Zada
Dr. Neal Mozen
Dr. Thomas Belken
Dr. Latasha Walters
Dr. Bryan West