A 45-year-old man (weight 125kg) with history of hypertension, hyperlipidemia, coronary artery disease with chronic stable angina, type 2 diabetes mellitus, dyspepsia with gastric ulceration, and asthma presents to the emergency department for shortness of breath and leg pain/swelling after a 16-hour business flight. Vital signs include a blood pressure of 110/80 mmHg, heart rate of 95 beats/minutes, and respiratory rate of 20 breaths/minute. Pertinent laboratory values include a normal hemoglobin, Cr 1.0mg/dL, elevated D-dimer 2000 ng/ml, and undetectable high-sensitivity troponin. Computed tomography-angiography of the chest demonstrates bilateral segmental pulmonary emboli without evidence of right ventricular strain. Vascular ultrasound demonstrates a proximal deep vein thrombosis in the right popliteal vein. His medications include metformin, empagliflozin, pantoprazole, lisinopril, verapamil, atorvastatin, and albuterol inhaler. He has no known drug allergies. He has insurance through his employer.
Which of the following anticoagulation regimens would be most appropriate for this patient's initial management of venous thromboembolism (VTE)?
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The correct answer is: A. Enoxaparin 1mg/kg every 12 hours with bridging to warfarin with a goal INR 2-3.
The listed options are all appropriate options for the management of acute/initial venous thromboembolism (VTE). It should be noted that both the Chest and American Society of Hematology guidelines recommend the use of the direct acting oral anticoagulants (DOACs) as the first line therapy for the management of VTE. However, selection of therapy should consider the patient presentation, patient characteristics, pharmacokinetics/pharmacodynamics, and patient adherence. Despite his weight, recent data suggest that DOACs are effective in patients with obesity. However, there are several patient characteristics that make the use of DOACs less than optimal. The patient has a history of dyspepsia, and thus dabigatran is not the optimal choice as it may worsen dyspepsia (Answer B is incorrect) due to its acid-based formulation. The patient is on verapamil for angina. Verapamil is a moderate CYP 3A4 inhibitor, which could lead to increased concentrations of factor Xa inhibitors (apixaban and rivaroxaban). Also, rivaroxaban may not be ideal given his ulcer history and potential increased risk of gastrointestinal bleeding with its use (Answers C and D are incorrect). Based on the combination of patient factors, the use of warfarin would be the most optimal choice. However, it should be noted, a shared-decision discussion should occur with the patient to assure optimal adherence.
Drs. Geoffrey Barnes, MD, MSc, FACC and Stanislav Henkin, MD, FACC served as peer reviewers for this patient case.
Supported by an educational grant from Janssen Pharmaceuticals, Inc., administered by Janssen Scientific Affairs, LLC.
To visit the Online Course page for the Practical Management of VTE: Simplifying Anticoagulation Strategies Grant, click here!
References
Stevens SM, Woller SC, Kreuziger LB, et al. Antithrombotic Therapy for VTE Disease: Second Update of the CHEST Guideline and Expert Panel Report [published online ahead of print, 2021 Aug 2]. Chest 2021;S0012-3692(21)01506-3.
Ortel TL, Neumann I, Ageno W, et al. American Society of Hematology 2020 guidelines for management of venous thromboembolism: treatment of deep vein thrombosis and pulmonary embolism. Blood Adv 2020;4:4693-738.
Renner E, Barnes GD. Antithrombotic Management of Venous Thromboembolism: JACC Focus Seminar. J Am Coll Cardiol 2020;76:2142-54.
Martin KA, Beyer-Westendorf J, Davidson BL, Huisman MV, Sandset PM, Moll S. Use of direct oral anticoagulants in patients with obesity for treatment and prevention of venous thromboembolism: Updated communication from the ISTH SSC Subcommittee on Control of Anticoagulation. J Thromb Haemost 2021;19:1874-82.
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