What is the best management approach for an 82-year-old male with a history of Deep Vein Thrombosis (DVT) on long-term anticoagulation and chronic right shoulder pain during an annual wellness visit?

Management of Long-Term Anticoagulation in an Elderly Patient with Prior DVT

For an 82-year-old male with a history of DVT on long-term anticoagulation, the optimal approach is to continue indefinite anticoagulation therapy with periodic reassessment of risks and benefits, while addressing his chronic shoulder pain with non-NSAID pain management options.

Anticoagulation Management

Assessment of Anticoagulation Need

• This patient falls into the category requiring indefinite anticoagulation as he has:
  • Prior DVT (likely unprovoked or recurrent based on long-term therapy)
  • Advanced age (82 years) which increases both thrombotic and bleeding risks
  • Stable clinical status with acceptable lab values 1

Anticoagulation Recommendations

• Continue current anticoagulation therapy indefinitely with periodic reassessment
• If on warfarin:
  • Maintain INR target of 2.0-3.0
  • Monitor INR regularly (every 4-6 weeks if stable)
  • Assess for drug-drug interactions with any new medications 1, 2
• If on DOAC:
  • Ensure appropriate dosing based on renal function
  • Monitor renal function every 3-6 months (more frequently if CrCl <50 mL/min) 1

Monitoring Parameters

• Regular assessment of:
  • Bleeding risk (examine for bruising, occult blood in stool)
  • Thrombotic risk (symptoms of recurrent DVT)
  • Renal function (especially important if on DOAC)
  • Complete blood count
  • Liver function tests 1

Management of Chronic Shoulder Pain

Pain Management Approach

• Avoid NSAIDs due to increased bleeding risk with anticoagulation
• First-line options:
  • Acetaminophen (up to 3g daily, with reduced dose in elderly)
  • Physical therapy focused on maintaining range of motion
  • Topical analgesics (lidocaine patches, capsaicin)
• Second-line options:
  • Low-dose tramadol if needed for breakthrough pain
  • Consider orthopedic evaluation if pain worsens or function declines

Precautions

• Avoid intramuscular injections when possible due to bleeding risk
• If corticosteroid injection is considered for shoulder pain:
  • Coordinate with anticoagulation management
  • Consider temporary adjustment of anticoagulation if procedurally necessary

Comprehensive Annual Wellness Assessment

Key Elements to Address

• Evaluate for signs/symptoms of post-thrombotic syndrome
• Assess mobility and fall risk (particularly important in anticoagulated patients)
• Review medication list for potential interactions with anticoagulants
• Consider compression stockings if there are signs of post-thrombotic syndrome 1
• Screen for cognitive changes that might affect medication adherence

Patient Education

• Reinforce importance of anticoagulation adherence
• Discuss bleeding precautions and when to seek medical attention
• Provide guidance on activity modifications to minimize shoulder pain while maintaining function
• Ensure patient understands signs/symptoms of recurrent DVT or bleeding complications

Follow-up Recommendations

• Schedule next visit in 3-6 months to reassess anticoagulation and pain management
• Consider more frequent monitoring if changes are made to either anticoagulation or pain management regimen
• Annual comprehensive reassessment of risks and benefits of continued anticoagulation 1

Common Pitfalls to Avoid

• Discontinuing anticoagulation without thorough risk assessment (this patient likely needs indefinite therapy)
• Adding NSAIDs for shoulder pain management (significantly increases bleeding risk)
• Failing to monitor renal function in elderly patients on anticoagulants
• Neglecting to periodically reassess the risk-benefit ratio of continued anticoagulation
• Overlooking potential drug interactions with anticoagulants when prescribing new medications