Pharmacotherapy Case Study: Deep Vein Thrombosis (DVT) by Dr. Nehad Ahmed


Patient Profile: 45-year-old female

Subjective Data

  • Chief Complaint: “My left leg is swollen, red, and hurts when I walk. It started two days ago.”

  • History of Present Illness:

    • Sudden-onset left calf pain and swelling after a 12-hour international flight 1 week ago.

    • Worsening erythema and warmth over the left lower leg; difficulty bearing weight.

    • Denies chest pain, dyspnea, or hemoptysis (no signs of pulmonary embolism).

  • Medical History:

    • Previous DVT 5 years ago (provoked by oral contraceptive use).

    • Family history of thrombophilia (sister with Factor V Leiden mutation).

    • No recent surgery, trauma, or active cancer.

  • Medications:

    • Occasional ibuprofen for headaches (last dose 3 days ago).

    • No prior anticoagulant use (discontinued warfarin after prior DVT resolved).

  • Social History:

    • Works as a flight attendant (frequent long-haul travel).

    • Nonsmoker, no alcohol use.

Objective Data

  • Vitals:

    • BP: 130/80 mmHg, HR: 88 bpm, RR: 16/min, SpO₂: 98% on room air.

    • BMI: 27 kg/m².

  • Physical Exam:

    • Left Lower Extremity:

      • Calf circumference 3 cm larger than right; erythema and tenderness on palpation.

      • Positive Homan’s sign (pain on dorsiflexion).

    • Cardiopulmonary: Lungs clear, no jugular venous distension.

  • Diagnostic Studies:

    • Doppler Ultrasound: Non-compressible left popliteal vein with intraluminal thrombus.

    • Labs:

      • D-dimer: 1,200 ng/mL (elevated).

      • CrCl: 85 mL/min (Cockcroft-Gault), platelets: 220,000/µL.

      • Negative pregnancy test.

Assessment

  1. Primary Diagnosis:

    • Acute Deep Vein Thrombosis (DVT) of the left lower extremity (provoked by prolonged immobility).

  2. Risk Stratification:

    • Moderate recurrence risk (prior DVT, thrombophilia family history).

    • Padua Prediction Score: 4 (prior VTE, immobility).

  3. Complications:

    • Low risk of pulmonary embolism (no symptoms).

Pharmacotherapy Plan

  1. Immediate Anticoagulation:

    • Direct Oral Anticoagulant (DOAC):

      • Rivaroxaban 15 mg twice daily × 21 days, then 20 mg once daily (total duration: 3–6 months).

    • Alternative if DOAC contraindicated:

      • Enoxaparin 1.5 mg/kg SC daily + transition to warfarin (target INR 2–3).

  2. Symptom Management:

    • Compression Stockings (30–40 mmHg) to reduce post-thrombotic syndrome risk.

    • Acetaminophen PRN for pain (avoid NSAIDs due to bleeding risk).

  3. Long-Term Considerations:

    • Duration of Therapy: Minimum 3 months (extend to 6+ months if unprovoked or high recurrence risk).

    • Thrombophilia Workup: Test for Factor V Leiden, prothrombin gene mutation.

Monitoring

  • Weekly: Assess for bleeding (epistaxis, melena), adherence, and symptom resolution.

  • 3-month follow-up: Repeat ultrasound to confirm thrombus resolution.

  • Lab Monitoring:

    • Renal function (CrCl) annually (adjust DOAC if CrCl <30 mL/min).

    • Liver enzymes (baseline and PRN for rivaroxaban).

Patient Education

  • Medication Adherence: Critical to prevent clot extension or recurrence.

  • Bleeding Precautions: Avoid NSAIDs, report signs of bleeding (e.g., bruising, blood in stool).

  • Lifestyle:

    • Ambulate frequently during travel; use compression stockings.

    • Hydrate well on long flights.

Rationale

  • Rivaroxaban: First-line DOAC for DVT with predictable pharmacokinetics and no routine monitoring.

  • Compression Therapy: Reduces post-thrombotic syndrome risk by 50%.

  • Avoid NSAIDs: Synergistic bleeding risk with anticoagulants.

  • Thrombophilia Testing: Guides long-term therapy duration (e.g., indefinite anticoagulation for genetic mutations).

Key Considerations:

  • Contraindications to DOACs: Severe renal impairment (CrCl <30 mL/min), pregnancy (use LMWH instead).

  • Bleeding Reversal: Andexanet alfa for rivaroxaban; idarucizumab for dabigatran.

  • Recurrence Risk: Extended anticoagulation if unprovoked or high thrombophilia risk.

Follow-Up Plan:

  • 1 week: Assess tolerability of rivaroxaban and compliance.

  • 3 months: Re-evaluate thrombus resolution and consider discontinuing anticoagulation if provoked.

  • 6 months: Thrombophilia results review; shared decision-making on long-term therapy.

This structured approach balances efficacy, safety, and patient-specific factors to optimize outcomes in acute DVT management.

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