Heparin Bridge: Immediate Anticoagulation Therapy

For individuals with a high risk of blood clot, warfarin provides long-term anticoagulation but requires several days to achieve its full therapeutic effect; in this context, a heparin bridge is often used to provide immediate anticoagulation. Specifically, heparin injection is used as bridging therapy, because warfarin has a delayed onset of action. Overlapping heparin with warfarin allows for immediate anticoagulation while waiting for warfarin to reach a therapeutic level.

Okay, let’s dive into the world of blood thinners! Imagine your blood vessels are like a superhighway, and blood clots are like unexpected traffic jams. Anticoagulation is basically the traffic control system, making sure everything flows smoothly and prevents those pesky clots from forming in the first place. It plays a crucial role in preventing conditions like stroke, heart attack, and venous thromboembolism.

Now, sometimes, when doctors prescribe warfarin (a common anticoagulant), it’s not an instant fix. Warfarin is like a slow-acting superhero; it takes a few days to build up its clot-busting powers. That’s where bridging therapy comes in. Think of it as a temporary, speedy sidekick that steps in while warfarin is getting ready for action. Its main purpose is to provide immediate anticoagulation and protect the patient from clotting events until warfarin reaches its therapeutic level.

So, what’s this “sidekick” we’re talking about? It’s often heparin! Heparin acts as the “bridge,” providing that quick anticoagulation boost while warfarin gradually takes over. This is super important in situations where waiting isn’t an option. For example, if you’ve got atrial fibrillation (an irregular heartbeat that can increase stroke risk), a recent blood clot, or a mechanical heart valve, bridging is often considered.

Keep in mind, this is a complex area, and your doctor will consider your specific situation when deciding if bridging is right for you. It’s not a one-size-fits-all solution, and treatment should always be guided by a healthcare professional. So, don’t try this at home, folks! This blog post is for informational purposes only, and it’s essential to consult with your healthcare provider for personalized advice.

Understanding the Dynamic Duo: Heparin and Warfarin

Let’s untangle the tale of two anticoagulants: our buddy heparin and its pal, warfarin. Think of them as a superhero team-up, each with its own special power, but working towards the same goal: keeping those pesky blood clots at bay! They’re like Batman and Superman of the blood-thinning world.

Heparin: The Speedy Sidekick

Heparin’s Mechanism of Action

So, first up, we have heparin, the indirect thrombin inhibitor. Now, what does that even mean? Think of thrombin as the villain causing all the clotting chaos. Heparin doesn’t directly punch thrombin in the face. Instead, it’s more like a crafty sidekick, increasing the power of antithrombin (another substance in your blood), which then neutralizes thrombin. Sneaky, right?

Unfractionated Heparin (UFH) vs. Low Molecular Weight Heparin (LMWH)

Heparin comes in two flavors: Unfractionated Heparin (UFH) and Low Molecular Weight Heparin (LMWH).

Key Differences Between UFH and LMWH

• Mechanism Nuances: Both boost antithrombin, but LMWH is a bit more selective, focusing on certain clotting factors.
• Bioavailability: LMWH is the showman. It absorbs into the bloodstream more predictably, which means more reliable action. UFH is a bit shy and doesn’t always absorb the same way.
• Half-Life: LMWH hangs around longer, so you don’t need as many doses. UFH is quick to come and go.
• Monitoring: UFH needs constant babysitting with a blood test called aPTT to make sure you’re in the sweet spot. LMWH is more independent, requiring less frequent monitoring.
• Examples: For LMWH, we’ve got rockstars like Enoxaparin (Lovenox), Dalteparin (Fragmin), and Tinzaparin (Innohep).

Warfarin: The Patient Strategist

Warfarin’s Mechanism of Action

Then we’ve got warfarin, the Vitamin K antagonist. Warfarin messes with Vitamin K, which is essential for making clotting factors. Think of it like this: Vitamin K is the chef, and clotting factors are the dishes. Warfarin hides all the ingredients, so the chef can’t cook!

Brand Names: Coumadin and Jantoven

You might know warfarin by its stage names: Coumadin and Jantoven.

Therapeutic Goals and INR

The goal with warfarin is to hit that sweet spot: a target INR range. INR stands for International Normalized Ratio. It’s a measure of how long it takes your blood to clot. Too low, and you risk a clot; too high, and you risk bleeding. It’s like Goldilocks and the Three Bears, but with blood! Getting this range right is super important for safe and effective treatment.

So, that’s the scoop on our dynamic duo. Heparin is fast-acting but needs constant monitoring, while warfarin is slow and steady, requiring regular check-ups to make sure everything’s in balance. Together, they are a force to be reckoned with in the fight against blood clots.

When is Bridging Necessary? Common Indications

Alright, let’s talk about the scenarios where we bring in the heparin bridge to get you safely onto warfarin. Think of it like this: Warfarin is like a long-haul truck – reliable but slow to get going. Heparin is the speedy race car that gets you protected right away. So, when do we need that initial burst of speed?

Atrial Fibrillation (AFib)

AFib is like a party in your heart where the rhythm goes wild. And unfortunately, this can lead to clot formation and potentially a stroke. Yikes!

• The Stroke Risk: With AFib, the upper chambers of your heart (atria) quiver instead of squeeze properly. This can cause blood to pool and form clots that can travel to the brain and cause a stroke.
• CHA2DS2-VASc Score: Doctors use a tool called the CHA2DS2-VASc score to figure out your stroke risk. It’s like a points system based on things like age, history of heart failure, diabetes, and prior stroke. The higher the score, the higher the risk.
• Bridging Recommendations: If your CHA2DS2-VASc score is high enough, your doctor will likely recommend bridging with heparin when starting warfarin to give you immediate protection while the warfarin kicks in.

Venous Thromboembolism (VTE)

VTE is a fancy term for blood clots in your veins, which can be a serious problem. Think of it as a traffic jam in your bloodstream.

• Defining VTE: VTE includes Deep Vein Thrombosis (DVT), which is a clot in a deep vein, usually in the leg, and Pulmonary Embolism (PE), which is when a clot travels to the lungs. Neither sounds like fun, right?
• Why Bridging for VTE? When you’ve already got a VTE, you need anticoagulation ASAP. Warfarin is great for long-term prevention, but it takes time to work. That’s why heparin is often used as a bridge to provide immediate protection while the warfarin gets you covered for the long run.

Mechanical Heart Valves

If you’ve got a mechanical heart valve, you’re in a higher risk category for forming clots. These valves, while life-saving, can create turbulence in the blood flow, increasing the chance of clot formation.

• The Thromboembolism Risk: Mechanical heart valves are lifesavers, but blood tends to stick to foreign surfaces. This can lead to clots that block blood vessels.
• High-Risk Scenarios: People with mechanical heart valves, especially in the mitral position or those with older valve models, need bridging, especially if their INR is subtherapeutic and requires hospitalization for IV anticoagulation. This is where heparin is absolutely essential to prevent potentially devastating complications.

Post-operative States

Recovering from surgery, especially major orthopedic surgeries like hip or knee replacements, increases your risk of blood clots. It’s like your body is so focused on healing that it gets a little too enthusiastic about clotting.

• Increased Thrombosis Risk: After certain surgeries, your body’s natural clotting mechanisms can go into overdrive, increasing the risk of DVT or PE.
• When Bridging is Considered: Bridging might be considered after surgeries like hip or knee replacements, especially if you have other risk factors for clotting. It’s a way to provide extra protection during this vulnerable period.

Important Note: Bridging therapy is a complex decision that depends on your individual situation. Always work closely with your healthcare team to determine the best course of action for you.

Monitoring the Bridge: Key Lab Tests and What They Mean

Alright, so you’re on this bridging therapy adventure, and you’re probably wondering, “How do I know this is actually working?!” That’s where these magical lab tests come in. Think of them as your compass and map, guiding you through the anticoagulation wilderness. Let’s break down the key players:

International Normalized Ratio (INR)

This is your main man when it comes to warfarin. The INR is like a report card for your blood’s clotting ability. It tells you how long it takes for your blood to clot, standardized so that labs across the world can speak the same language.

• Why it matters: Warfarin works by slowing down your blood’s clotting process. The INR helps your doctor figure out if you’re in the sweet spot – not clotting too fast (risk of clots) and not clotting too slow (risk of bleeding).
• Target range: This varies depending on why you’re taking warfarin, usually between 2.0 and 3.0. Your doctor will tell you your personal target range.
• Frequency: When you first start warfarin, you’ll be getting your INR checked often, maybe even daily. As you become more stable, the frequency will decrease.
• Dosage adjustments: Based on your INR, your doctor will adjust your warfarin dose to keep you within that target range. Think of it like a seesaw: too high, lower the dose; too low, raise the dose.

Prothrombin Time (PT)

PT, INR’s not-so-famous sibling, is the raw measurement that goes into calculating the INR.

• Relationship to INR: The INR is derived from the PT, but it’s standardized to account for differences between labs. So, while the PT is important, the INR is what your doctor will primarily focus on. Think of PT as the ingredient, and INR as the delicious cake.

Activated Partial Thromboplastin Time (aPTT)

This test is heparin’s best friend, specifically Unfractionated Heparin (UFH). It measures how long it takes for your blood to clot when UFH is in the picture.

• Why it matters: UFH directly affects the aPTT, so this test helps your doctor make sure you’re getting the right dose.
• Target range: Like the INR, there’s a target aPTT range for therapeutic anticoagulation with UFH. Your doctor will aim for a specific range (often around 1.5 to 2.5 times the normal value).
• Monitoring: The aPTT is usually monitored regularly when you’re on UFH, especially in the hospital.

Platelet Count

Hold up! Now we’re talking about platelets, those little guys that are supposed to help your blood clot. So why are we checking them if we’re trying to prevent clots?

• Heparin-Induced Thrombocytopenia (HIT): This is a rare but serious complication of heparin therapy where heparin paradoxically causes a decrease in platelets. This can then increase the risk of clots! Crazy, right?
• Why it matters: Monitoring your platelet count helps catch HIT early. If your platelets drop significantly while you’re on heparin, your doctor will investigate further.

Complete Blood Count (CBC)

The CBC is a comprehensive blood test that gives you an overview of your blood cells, including platelets.

• Why it matters: Although a platelet count alone is sufficient for monitoring thrombocytopenia, CBC is a part of HIT monitoring.
  *Reinforces the importance of monitoring CBC during anticoagulant
  therapy.

Renal Function

Your kidneys play a bigger role in all of this than you might think!

• Why it matters: Your kidneys help clear both heparin (especially Low Molecular Weight Heparin (LMWH)) and warfarin from your body. If your kidneys aren’t working well, these drugs can build up, increasing the risk of bleeding.
• Assessment: Your doctor will likely check your kidney function (e.g., creatinine clearance) before starting anticoagulation and periodically during treatment.
• Dosing: If you have kidney problems, your doctor may need to adjust the dose of heparin or warfarin to keep you safe. So, make sure to tell them about any kidney issues!

In summary, these lab tests are your allies in navigating the sometimes-tricky world of bridging therapy. They help your doctor fine-tune your treatment to keep you safe and prevent both clots and bleeding. Remember to ask questions and be an active participant in your care!

Navigating the Risks: Bleeding, Thrombosis, and HIT

Okay, let’s talk about the not-so-fun part of bridging therapy: the potential bumps in the road. While heparin and warfarin are lifesavers, they come with their own set of risks. It’s like driving a powerful sports car – exhilarating, but you gotta know how to handle it!

Bleeding Risk: Spotting the Warning Signs

First up, bleeding. Since we’re thinning the blood, it’s no surprise that bleeding is the main concern. Think of it like this: your blood vessels are roads, and anticoagulants are snowplows keeping them clear. But too much plowing, and you might scrape the pavement!

• What makes bleeding more likely? Age (sorry, folks!), other medical conditions (comorbidities), and even some of your other medications. It’s a whole cocktail of factors.

• How do we keep things under control? Careful patient selection (not everyone’s a good candidate for intense anticoagulation), spot-on dosing, and vigilant monitoring for any signs of bleeding. This means keeping an eye out for unusual bruising, nosebleeds, or blood in your stool or urine.

• Help! Too much warfarin! Vitamin K is our antidote! It helps reverse warfarin’s effects if things go too far. Think of it as the “undo” button for your blood’s clotting ability.

• Heparin Overdose? Protamine sulfate to the rescue! It works like a magnet, binding to heparin and neutralizing its effects. It’s most effective for UFH but can also help with LMWH, though to a lesser extent.

Thrombosis Risk: A Tricky Rebound

Ironically, while we’re trying to prevent blood clots, there’s also a risk of thrombosis when anticoagulation is interrupted. Imagine stopping that snowplow in the middle of a blizzard – things can quickly get icy again!

• Why does this happen? Stopping anticoagulants, even temporarily (like for surgery), can allow the blood to clot more easily.
• Our Strategy? Using shorter-acting anticoagulants if possible, or restarting your meds ASAP after the interruption. It’s all about minimizing the time your blood is unprotected.

Heparin-Induced Thrombocytopenia (HIT): The Paradoxical Plot Twist

Now, for the curveball: Heparin-Induced Thrombocytopenia, or HIT. This is where things get a bit twisted.

• What is HIT? It’s a rare but serious condition where your body reacts to heparin, causing your platelet count to drop. Now, platelets help with clotting, so you’d think a low platelet count would mean less clotting risk, right? Wrong! In HIT, the body also forms antibodies that activate the remaining platelets, leading to a higher risk of paradoxical thrombosis. It’s like your blood is having a civil war!

• How do we diagnose it? We use the “4Ts” scoring system and lab tests. The 4Ts are: Thrombocytopenia (low platelet count), Timing (when the platelet drop occurred), Thrombosis (presence of new blood clots), and other causes for Thrombocytopenia.

• How do we treat it? First, stop the heparin immediately! Then, we switch to alternative anticoagulants that don’t trigger the same reaction, such as argatroban or fondaparinux. It’s like changing horses mid-race!

So, there you have it – a rundown of the risks and how we navigate them. Remember, your healthcare team is always there to guide you and make sure your treatment is safe and effective.

Perioperative Bridging: A Delicate Balance – The Tightrope Walk of Anticoagulation!

Okay, folks, imagine you’re a circus performer, and your act involves walking a tightrope. On one side, you have the ravenous lions of thrombosis snapping at your heels. On the other, the perilous pit of bleeding yawns below. That, in a nutshell, is perioperative bridging! It’s all about carefully planning and timing your anticoagulant moves around surgery, balancing the risks as precisely as possible.

The Pre-Op Huddle: Assess, Plan, and Maybe Panic (Just a Little)

Before the surgical curtain rises, there’s some serious planning involved. We’re talking about figuring out how to temporarily halt anticoagulation for the procedure without unleashing those thrombotic lions. Key considerations? Think of it as a pre-game huddle:

• Type of Surgery: A minor skin procedure is vastly different from open-heart surgery. The risk of bleeding varies hugely.
• Patient’s Underlying Thrombotic Risk: Is our patient a mechanical heart valve owner or someone with a history of recurrent VTE? Higher risk means more aggressive bridging. The patient’s risk should be underlined.
• Renal Function: Kidneys play a big role in clearing these meds. If they’re not working well, drug levels can go haywire.
• Specific Anticoagulant Used: Are we talking about warfarin, LMWH, or something else? Each has a different half-life and requires a unique approach.

The Art of the Stop and Start: Timing is Everything!

Stopping anticoagulation is not like flipping a switch. We have to carefully time it so that the drug effect wears off enough to allow for surgery without excessive bleeding, but not so much that we leave the patient unprotected.

• Warfarin: Typically, warfarin is stopped about 5 days before surgery, allowing the INR to drop below 1.5.
• LMWH: LMWH is usually held 24 hours before surgery.

Restarting is equally delicate. Too soon, and you risk a bleed. Too late, and… well, you know about those lions!

Standardizing the Circus Act: Guidelines to the Rescue

Luckily, we’re not flying completely blind. Guidelines and protocols exist to help standardize perioperative anticoagulation management. These resources provide evidence-based recommendations for different scenarios, helping to ensure a consistent and safe approach. Think of them as the safety net that keeps our circus performer (and our patient) from falling.

Pharmacokinetics and Pharmacodynamics: It’s All About the Journey and the Impact!

Ever wonder why your doctor tweaks your medication dosage? Well, buckle up, because we’re diving into the fascinating world of pharmacokinetics and pharmacodynamics – fancy words for how drugs move through your body and what effects they have. Think of it as the drug’s epic adventure inside you!

First up, pharmacokinetics: This is all about what your body does to the drug. It’s a four-part story:

• Absorption: How the drug gets into your bloodstream. Heparin, for instance, is usually injected because your gut can’t absorb it well. Warfarin, on the other hand, happily hops on board from your digestive system.
• Distribution: Where the drug goes once it’s in your blood. Does it hang out in your tissues, or does it stay mainly in the bloodstream?
• Metabolism: How your body breaks down the drug. Your liver is the star of this show, working hard to process medications.
• Excretion: How your body gets rid of the drug. Usually, it’s through your kidneys and out in your urine.

These processes all influence how much of the drug is available in your body and for how long, which, in turn, affects the dosage and frequency your doctor prescribes, plus how often you need to be monitored.

Now, let’s talk pharmacodynamics: This is about what the drug does to your body. It’s all about how the drug interacts with your system to produce its effects. Are you blocking a specific pathway? Are you inhibiting the effect of a factor? How well the drug binds with its target will contribute to variability in how well someone responds to the drug. Some people might need a higher dose to achieve the same effect, while others are super-sensitive and need much less.

Ultimately, both pharmacokinetics and pharmacodynamics help your healthcare provider personalize your medication plan.

Drug Interactions: Watch Out for These Combinations

• Medication interactions can be a real party pooper when you’re on anticoagulants like warfarin and heparin! It’s like inviting uninvited guests who start rearranging the furniture – in this case, messing with your blood’s ability to clot properly. So, let’s talk about some of these troublemakers!

• Warfarin, bless its heart, is a bit of a drama queen. It’s super sensitive to what else is going on in your system. Loads of medications can throw its INR levels off, leading to potential issues. For example:

  • Antibiotics: Some, like the macrolides (think erythromycin or clarithromycin) or certain fluoroquinolones (like ciprofloxacin), can send your INR soaring. Others might actually lower it. It’s a bit of a mixed bag.
  • Antifungals: Medications like fluconazole or ketoconazole can also raise your INR, increasing the risk of bleeding.
  • NSAIDs (Nonsteroidal Anti-Inflammatory Drugs): Common pain relievers like ibuprofen (Advil, Motrin) or naproxen (Aleve) can increase bleeding risk when taken with warfarin, even if they don’t drastically change the INR. The problem is these medications stop your platelets from working correctly.
  • Herbal supplements: Even natural remedies aren’t off the hook! St. John’s Wort can actually decrease warfarin’s effectiveness by speeding up its metabolism, increasing the risk of clots.

• Now, imagine your INR is a seesaw. Certain drugs push it too high, increasing the risk of bleeding (think nosebleeds, bruising easily, or even more serious internal bleeds). Others push it too low, upping the risk of a blood clot forming. It’s like a balancing act, and these interactions can really knock you off balance.

• And don’t forget about heparin! While it might not have as many direct interactions affecting its blood levels, using it with other anticoagulants or antiplatelet drugs (like aspirin or clopidogrel) can significantly bump up your bleeding risk. It’s like adding fuel to the fire.

• That’s why a thorough medication review is absolutely crucial. When starting or changing meds, always let your doctor know you’re on warfarin or heparin. Also, it may be important to notify your anticoagulation provider. They can keep a closer eye on your INR, adjust your dosage, and help you steer clear of any potential drug interaction disasters. A little bit of awareness and caution can go a long way in keeping you safe and sound!

Patient Education: Empowering Patients for Safe Anticoagulation

Hey there, knowledge seeker! Let’s be real – starting anticoagulation, especially with the whole “bridging” thing, can feel like navigating a maze blindfolded. But guess what? You don’t have to! Understanding your treatment plan is super important for keeping you safe and sound. Think of it like this: you’re the captain of your ship, and we’re just giving you the map and compass. But, if you don’t look at the map, that doesn’t help right?

Why does your understanding even matter? Well, simply put, adherence is key. If you don’t know why you’re taking these meds or how to take them correctly, things can go sideways. We want you to be an active participant in your care, not just a passive passenger. The more you understand, the better you can partner with your healthcare team.

Key Elements of Patient Education: Your Anticoagulation Survival Guide

Alright, let’s dive into the essential stuff you need to know. Consider this your anticoagulation cheat sheet!

• Purpose of Anticoagulation and Bridging Therapy: First off, why are you even doing this? It’s all about preventing blood clots. Anticoagulants, like warfarin, are your shield against those pesky clots that can cause serious problems like strokes or pulmonary embolisms. Bridging therapy, usually with heparin, is like a temporary force field. It kicks in right away while warfarin slowly builds up its protective powers.

• How to Take Medications Correctly: Sounds simple, right? But there’s more to it than just swallowing a pill. Know the correct dose, when to take it (with or without food?), and what to do if you miss a dose. Never double up on doses! Always ask your doctor or pharmacist if you’re unsure. They’re there to help!

• The Importance of Regular INR Monitoring (for Warfarin): If you’re on warfarin, you’ll become best friends with the INR test. This test measures how well your blood is clotting. Think of it as checking the oil level in your car – it helps make sure everything’s running smoothly. Your doctor will use the INR to adjust your warfarin dose to keep you in the sweet spot – not too thin (bleeding risk) and not too thick (clotting risk).

• Signs and Symptoms of Bleeding and Thrombosis: This is crucial! You need to know what to watch out for. On the bleeding side, think unusual bruising, nosebleeds that won’t stop, blood in your urine or stool, or very heavy menstrual periods. On the thrombosis side, watch for swelling, pain, redness, or warmth in your leg (DVT) or sudden shortness of breath, chest pain, or coughing up blood (PE). If you notice any of these, call your doctor immediately!

• Drug and Food Interactions to Avoid: Warfarin is a bit of a diva – it doesn’t play well with certain foods and medications. Vitamin K-rich foods (think leafy greens like spinach and kale) can interfere with warfarin’s effects. Also, many common medications, like antibiotics and NSAIDs (ibuprofen, naproxen), can affect your INR. Always tell your doctor and pharmacist about everything you’re taking, including over-the-counter meds and supplements.

• The Need to Inform All Healthcare Providers About Anticoagulation Therapy: This is non-negotiable! Every doctor, dentist, and even your massage therapist needs to know you’re on anticoagulants. This is especially important before any surgery or procedure, as they may need to adjust your medication. Make it a habit to mention it every time.

By being informed and engaged, you’re not just a patient – you’re a partner in your healthcare. And that’s the best way to navigate the world of anticoagulation!

Clinical Process: From Anticoagulation Initiation to Thromboembolic Event Management

Okay, let’s break down the clinical process, because it’s not as scary as it sounds, promise! We’re talking about what happens when someone needs anticoagulation – you know, blood thinners – whether it’s because of a past health scare or to prevent one.

Imagine a world where blood clots are like uninvited guests at a party. Anticoagulation is essentially the bouncer, making sure things don’t get too crowded or, in this case, blocked. For anyone with a history of stroke, TIA (mini-stroke), DVT (deep vein thrombosis), or PE (pulmonary embolism), anticoagulation is absolutely crucial. It’s like having a safety net, protecting you from a repeat performance of these thromboembolic events.

Now, let’s talk about what happens when you have a health scare with thromboembolic events.
For the management of these conditions, the main goals are:
* Prevention of progression
* Prevention of reoccurrence

Perioperative Medication Management

Navigating medications around surgery can feel like walking a tightrope but don’t you worry!. You’ve got to carefully balance the risk of bleeding with the risk of clotting. So, what’s perioperative medication management? Well, before any procedure, doctors need to decide whether to hold or continue anticoagulation. Factors like the type of surgery, your individual clotting risk, and kidney function all play a part.

It’s a bit like a high-stakes game of chess, with doctors carefully strategizing each move to keep you safe and sound. Remember, transparency is key: Keep your healthcare providers in the loop about all the medications and supplements you are taking to minimize the risk of any adverse effects or complications.

Immediate Management of Thromboembolic Events

Alright, so what happens when an unwanted guest arrives at the party – meaning a thromboembolic event occurs? The goal is to act fast! Immediate management usually involves a high dose of anticoagulation to stop the clot from getting any bigger and prevent further complications.

Think of it like calling in the SWAT team to handle the situation before it escalates. Doctors might use heparin or other direct-acting anticoagulants to get things under control ASAP. The specific treatment depends on the type and severity of the event, as well as your overall health.

But remember, these events require hospitalization.

Disclaimer: This information is for educational purposes only. Consult with your healthcare provider for personalized medical advice.

So, there you have it! Bridging the gap from heparin to warfarin can seem like a bit of a balancing act, but with a good understanding of the process and close monitoring from your healthcare team, you’ll be navigating those INR levels like a pro in no time. As always, make sure to discuss any concerns with your doctor – they’re the best guide on this journey!