Case Presentation: Leg Pain

• CC: Right lower extremity pain

• HPI: JC is a 53 yo Hispanic male who presented to the ED with acute onset
of right lower extremity pain. The pain was located in the medial portion of
his right thigh. He reports no trauma or recent strenuous activity. The
previous week he went to the urgent care clinic with complaints of SOB,
DOE, and a stabbing chest pain. At that time he was diagnosed with
pneumonia, given antibiotics, and sent home. The pain subsided and he has
been feeling good until today when the acute leg pain started.
Past Medical History

• Myasthenia gravis with subsequent thymectomy many years ago

• Psoriasis and psoriatic arthritis
• Previous pain in leg and subsequent SOB 3 years ago at, which time patient
was diagnosed with a DVT and PE and treated with warfarin acutely and
transitioned to Eliquis for 6 months of treatment
Hospital course

• Doppler ultrasound in the ED revealed the presence of a DVT in the right femoral vein
• CT angiogram of chest also revealed PE and resulting pulmonary infarct in the right lung
base
• Patient was observed overnight and given Lovenox 1mg/kg subcutaneous BID and then
transitioned to Eliquis 10 mg PO BID with plan to continue at 5 mg BID until further
reevaluation
• Patient was asymptomatic the next day after ED visit and was discharged with instructions
to follow up at clinic in the next two weeks
• Upon further questioning patient endorses that he has recently been very stationary at work
lately, sitting at his desk for long periods without moving
 Deep Vein Thrombosis
• DVT occurs when a clot forms within the deep veins of the body, most
frequently in the legs
• The clot can then become dislodged and travel to the lungs causing a
pulmonary embolism
• Symptoms: localized pain, redness, swelling at the site of thrombus but can
be completely asymptomatic
 DVT Risk Factors
• Virchow’s triad: endothelial injury/dysfunction, hypercoagulable state, and venous
stasis
• Endothelial injury: recent surgery, hypertension, contact foreign materials such as implants
or medical devices
• Hypercoagulable state: cancer, nephrotic syndrome, factor V mutation, Antithrombin III
deficiency, protein C or S deficiency, pregnancy, smoking, oral contraceptives/hormone
replacement, obesity, antiphospholipid antibody syndromes, and older age (>60)
• Stasis: long car/plane rides, stationary jobs, bed ridden such as in hospital or nursing home
 DVT Workup
• Physical exam to look for redness, swelling, and tenderness in area
• Ultrasound study of affected area
• Blood work to check D-dimer levels (elevated in DVT/PE)
• CT/MRI of veins in area or in chest to check for PE
 DVT Treatment
• Initial treatment: heparin or lovenox (low molecular weight heparin) are
typically started first at hospital
• Continuing treatment: warfarin, rivaroxaban, apixaban
• For warfarin therapy patient will have to be continued on heparin or lovenox until
warfarin has reached therapeutic levels in the blood (follow INR to know when
therapeutic levels are reached, ideal range is between 2-3)
 Drug MOA
• Heparin and lovenox binds to antithrombin III creating an unfractionated heparin
and antithrombin III complex that irreversibly inactivates thrombin and Factor Xa
• Warfarin blocks vitamin K epoxide reductase thus inhibiting clotting factors II, VII,
IX, and X. Also inhibits protein C and S, which are clotting inhibitors. Protein C is
inhibited early on leading to hypercoagulable state. Takes a few days to inhibit these,
thus you have to do bridge therapy until it reaches therapeutic levels
• Rivaroxaban and apixaban are direct factor Xa inhibitors, bind directly to factor Xa
thus inhibiting coagulation cascade
 Treatment dosing
• Heparin: 80 units/kg bolus then 18 units/kg/hr
• Adjust as needed based on aPTT
• Enoxaparin (Lovenox): 1 mg/kg BID
• Warfarin (Coumadin ): start w/5 mg daily, Day 3-5: 0-10 mg based on INR, Day 6-
beyond 0-12.5 mg based on INR
• Apixaban (Eliquis): 10 mg BID
• Rivaroxabin (Xarelto): 15 mg BID for 3 weeks followed by 20 mg daily w/food
 Duration of Treatment
• First episode of DVT provoked or unprovoked: minimum 3 months
• Evidence shows that w/out anticoagulation risk of recurrent DVT/PE is highest
during 1st 3 months
• May extend to 6-12 months if patient has ongoing risk factors but benefits unproven
• 2nd episode of provoked DVT: 3 months
• 2nd episode of unprovoked DVT: indefinite anticoagulation
• These patients along with patients who have active cancer are likely to benefit for
indefinite anticoagulation
• Patients unlikely to benefit are provoked DVT, patients w/high bleeding risk
Based on 2016 American College of Chest
Physicians Guidelines
 Treatment Follow Up
• After patients are off of anticoagulation therapy, decision has to be made if
further workup is indicated to look for source of DVT
• i.e. checking factor V, protein C and S levels
• Educating patient on importance of remaining active and regular exercise to
reduce the likelihood of recurrence
 References
• https://www.mayoclinic.org/diseases-conditions/deep-vein-thrombosis/diagnosis-
treatment/drc-20352563
• http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/hematol
ogy-oncology/hypercoagulable-states/
• https://www.uptodate.com/contents/venous-thromboembolism-initiation-of-
anticoagulation-first-10-
days?source=machineLearning&search=enoxaparin%20dosing%20for%20dvt&sele
ctedTitle=3~150&sectionRank=1&anchor=H796357734#H796357767
• Sketchy Medicine