Pharmacotherapy Case 13: Chronic Anticoagulation Management by Dr. Nehad Ahmed

 

Age: 72 years

Gender: Male

Subjective Data

Chief Complaint:

“I’ve noticed some bruising on my arms and want to make sure my blood thinner is still safe.”

History of Present Illness:

Mr. Doe is a 72-year-old male with a history of non-valvular atrial fibrillation (AF), status post ischemic stroke 2 years ago, hypertension, and type 2 diabetes mellitus. He presents for a routine follow-up to manage chronic anticoagulation with apixaban. He reports occasional fatigue and lightheadedness but denies chest pain, palpitations, melena, hematochezia, or hematuria. He notes mild bruising on his arms from “bumping into furniture” but no spontaneous bleeding.

Medical History:

·        Atrial fibrillation (diagnosed 5 years ago)

·        Ischemic stroke (2 years ago, no residual deficits)

·        Hypertension

·        Type 2 diabetes mellitus

Family History:

·        Father: died of ischemic stroke at age 80.

·        Mother: hypertension, died at 78.

Social History:

·        Retired teacher, lives independently.

·        No tobacco use; occasional alcohol (1–2 glasses of wine/week).

Medications:

·        Apixaban 5 mg PO BID (for stroke prevention in AF)

·        Metformin 1000 mg PO BID

·        Lisinopril 20 mg PO daily

·        Atorvastatin 40 mg PO nightly

Allergies:

·        No known drug allergies.

Adherence:

·        Reports >90% adherence to medications.

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Objective Data

Vital Signs:

·        BP: 130/85 mmHg

·        HR: 78 bpm (irregularly irregular rhythm)

·        RR: 16 breaths/min

·        SpO2: 98% on room air

·        Weight: 82 kg

·        Height: 175 cm

Physical Exam:

·        Cardiovascular: Irregularly irregular rhythm, no murmurs.

·        Respiratory: Clear to auscultation bilaterally.

·        Skin: 2 small ecchymoses on forearms, no active bleeding.

·        Neurologic: Alert, oriented, no focal deficits.

Laboratory Results:

·        Creatinine: 1.1 mg/dL (eGFR 55 mL/min/1.73m²)

·        Hemoglobin: 13.8 g/dL (stable from prior)

·        Platelets: 220,000/µL

·        INR: Not applicable (on direct oral anticoagulant [DOAC]).

Diagnostics:

·        ECG: Atrial fibrillation with controlled ventricular rate.

·        Renal function: CrCl 55 mL/min (Cockcroft-Gault).

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Assessment

1.     Chronic Anticoagulation for Atrial Fibrillation:

o   CHA₂DS₂-VASc Score: 5 (Age 65–74 [1], Hypertension [1], Diabetes [1], Prior Stroke [2]). High stroke risk; anticoagulation indicated.

o   HAS-BLED Score: 2 (Age >65 [1], Hypertension [1]). Moderate bleeding risk.

2.     Current Anticoagulant:

o   Apixaban 5 mg BID is appropriate (CrCl >30 mL/min; no dose adjustment needed).

3.     Bruising:

o   Likely mechanical trauma (no lab evidence of thrombocytopenia or anemia).

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Plan

1.     Pharmacotherapy:

o   Continue apixaban 5 mg BID (benefit of stroke prevention outweighs bleeding risk).

o   Reassure patient that minor bruising is common with anticoagulants.

2.     Monitoring:

o   Annual renal function (CrCl) and CBC.

o   Assess for signs of bleeding or falls at each visit.

3.     Education:

o   Avoid NSAIDs; use acetaminophen for pain.

o   Report symptoms of bleeding (e.g., black stools, red urine, severe headaches).

o   Use soft-bristle toothbrush and electric razor to minimize bleeding risk.

4.     Follow-Up:

o   Return in 6 months or sooner if bleeding concerns arise.

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Rationale:

Apixaban is preferred over warfarin in this patient due to its lower bleeding risk, no dietary interactions, and no routine INR monitoring. Renal function remains stable, supporting continued use of standard dosing. Patient education focuses on mitigating bleeding risks while maintaining anticoagulation efficacy.