What is the most appropriate management for an 86-year-old woman with worsening left leg pain, redness, and firmness, diagnosed with a deep vein thrombosis (DVT), and a history of varicose veins, heart failure, and chronic recurrent urinary tract infections, currently on furosemide (Lasix) and valsartan (Diovan)?

From the Guidelines

The most appropriate management for this 86-year-old woman with DVT would be anticoagulation therapy with careful consideration of her age and comorbidities.

Key Considerations

• The patient's diagnosis of DVT, varicose veins, heart failure, and chronic recurrent urinary tract infections necessitate careful management to prevent clot propagation and pulmonary embolism.
• The patient's current medications, including furosemide and valsartan, should be reviewed for potential interactions with anticoagulants.
• Direct oral anticoagulants (DOACs) such as apixaban or rivaroxaban are recommended over vitamin K antagonist (VKA) therapy for the treatment of DVT, according to the most recent guidelines 1.

Treatment Options

• Apixaban (Eliquis) 10 mg twice daily for 7 days followed by 5 mg twice daily for at least 3 months would be a reasonable first-line option.
• Alternatively, rivaroxaban (Xarelto) 15 mg twice daily for 21 days followed by 20 mg once daily could be used.
• If DOACs are contraindicated, low molecular weight heparin (enoxaparin 1 mg/kg twice daily) bridging to warfarin with a target INR of 2-3 is appropriate, as recommended by the guidelines 1.

Additional Recommendations

• The patient should be advised to elevate the affected leg when seated, wear compression stockings (20-30 mmHg) once the acute phase resolves, and maintain adequate hydration.
• Regular monitoring of renal function is essential given her age and heart failure, with dose adjustments as needed, as suggested by the guidelines 1.
• Pain management with acetaminophen rather than NSAIDs is preferred to avoid worsening heart failure or renal function.
• The patient's medication regimen should be reviewed for potential interactions with anticoagulants, particularly monitoring for signs of fluid overload with her current heart failure medications. The most recent guidelines from 2024 1 provide the strongest evidence for the management of DVT, and should be followed in this case.

From the FDA Drug Label

The efficacy profile of apixaban was generally consistent across subgroups of interest for this indication (e.g., age, gender, race, body weight, renal impairment). Apixaban was shown to be noninferior to enoxaparin/warfarin in the AMPLIFY study for the primary endpoint of recurrent symptomatic VTE (nonfatal DVT or nonfatal PE) or VTE-related death over 6 months of therapy Efficacy and safety of apixaban for the treatment of DVT and PE, and for the reduction in the risk of recurrent DVT and PE following 6 to 12 months of anticoagulant treatment was derived from the AMPLIFY and AMPLIFY-EXT studies

The most appropriate management for this patient is initiation of anticoagulation therapy. The patient's symptoms and physical exam findings are consistent with a deep vein thrombosis (DVT), and anticoagulation therapy is the standard treatment for this condition.

• Anticoagulation therapy is recommended for the treatment of DVT to prevent the progression of the thrombosis and reduce the risk of pulmonary embolism.
• The patient's age, medical history, and current medications do not appear to be contraindications to anticoagulation therapy.
• The use of anticoagulation therapy in this patient is supported by the results of the AMPLIFY and AMPLIFY-EXT studies, which demonstrated the efficacy and safety of apixaban for the treatment of DVT and reduction in the risk of recurrent DVT and PE 2.

From the Research

Diagnosis and Management

• The patient's symptoms, including worsening pain, redness, and firmness in the left leg, along with a palpable cord, are suggestive of a deep vein thrombosis (DVT) [ 3 ].
• The patient's history of varicose veins, heart failure, and chronic recurrent urinary tract infections, as well as recent long-distance travel, increases her risk for DVT [ 4 ].

Treatment Options

• Initiation of anticoagulation therapy is the most appropriate management for DVT [ 3 ].
• Direct oral anticoagulants (DOACs) are first-line agents for treating venous thromboembolism, including DVT, and can be initiated in the outpatient setting for eligible patients [ 3 ].
• The choice of anticoagulant should be based on the patient's individual risk factors, including renal function, bleeding risk, and other comorbidities [ 4 ].

Considerations

• The patient's current medications, including furosemide and valsartan, should be considered when initiating anticoagulation therapy [ 5 ].
• The risk of bleeding should be assessed and monitored closely, using validated bleeding risk assessments such as HAS-BLED [ 3 ].
• Consultation with a hematologist or vascular surgeon may be necessary to guide management and ensure optimal outcomes [ 6 ].

Anticoagulation Therapy

• Anticoagulation therapy should be initiated as soon as possible to prevent further clot formation and reduce the risk of pulmonary embolism [ 3 ].
• The patient should be closely monitored for signs of bleeding or other complications, and the anticoagulation regimen should be adjusted as needed [ 7 ].