Should a patient with antiphospholipid syndrome, history of deep vein thrombosis (DVT), asthma, and a body mass index (BMI) issue, who is normally on Plavix (clopidogrel) and Eliquis (apixaban) but has been off for a few days, be admitted to the medical floor for a right great toe infection with a draining wound and a new non-occlusive DVT in one of the right gastrocnemius veins?

Hospital Admission Recommended for This High-Risk Patient

This patient should be admitted to the medical floor given the combination of active infection requiring IV antibiotics, new DVT while off anticoagulation, antiphospholipid syndrome with high thrombotic risk, and need for urgent anticoagulation resumption. 1, 2

Primary Indications for Admission

Active Infection Requiring Treatment

• Right great toe infection with draining wound necessitates prompt interdisciplinary care and likely IV antibiotics, particularly given the presence of PAD (failed popliteal stent) which increases amputation risk 3-fold when infection and vascular disease coexist 1
• Foot infections in patients with PAD require high index of suspicion and aggressive management to avoid amputation 1
• The combination of infection and vascular compromise warrants hospital-based coordinated care 1

New DVT While Off Anticoagulation

• Patient has developed a new non-occlusive DVT in the gastrocnemius vein while off Plavix and Eliquis for several days 1
• For acute isolated distal DVT (gastrocnemius vein), anticoagulation is recommended when risk factors for extension are present, which this patient clearly has: antiphospholipid syndrome, previous DVT history, and recent interruption of anticoagulation 1
• The 2021 CHEST guidelines recommend hospital admission for patients with significant comorbidities with risk of bleeding when managing VTE 1

Antiphospholipid Syndrome Considerations

• Patients with antiphospholipid syndrome have extremely high risk of recurrent thrombosis, with up to 20% of DVT cases associated with antiphospholipid antibodies 3
• The 2021 CHEST guidelines specifically recommend adjusted-dose VKA (warfarin) over DOACs for patients with confirmed antiphospholipid syndrome, suggesting apixaban (Eliquis) may not be optimal therapy 1
• DOACs should be avoided in patients with antiphospholipid syndrome, especially if triple-positive or with arterial thrombosis history 1
• The FDA label for apixaban specifically warns against use in patients with antiphospholipid syndrome, noting increased thrombosis risk in triple-positive patients 4

Anticoagulation Management Complexity

• Patients on anticoagulant medications that need prompt resumption should be considered for hospital admission 5, 2
• This patient requires bridging anticoagulation strategy given the interruption of dual therapy (Plavix + Eliquis) and new thrombotic event 1
• The combination of antiphospholipid syndrome and new DVT while off anticoagulation represents a high-risk scenario requiring supervised anticoagulation reinitiation 1, 3

Additional Risk Factors Supporting Admission

Multiple Comorbidities

• History of failed arterial stent indicates significant vascular disease 1
• BMI issues may complicate dosing and increase bleeding risk 1
• Asthma adds respiratory considerations if PE develops 1
• Patients with significant comorbidities with risk of bleeding should be admitted 1, 2

Social and Safety Considerations

• Patients with social concerns or lack of adequate follow-up should be admitted 1, 2
• The complexity of managing infection, resuming anticoagulation, and monitoring for DVT extension requires close observation 1

Recommended Inpatient Management

Immediate Actions

• Initiate therapeutic anticoagulation with LMWH or unfractionated heparin rather than resuming apixaban, given antiphospholipid syndrome diagnosis 1, 3
• Consider transition to warfarin (target INR 2.0-3.0) as preferred long-term anticoagulation for antiphospholipid syndrome 1, 3
• Obtain infectious disease and vascular surgery consultations for coordinated management of foot infection 1
• Perform serial imaging at 1 and 2 weeks to monitor for DVT propagation 1

Anticoagulation Strategy

• LMWH is recommended over warfarin for initial treatment, with overlap when transitioning to warfarin 1
• For patients with antiphospholipid syndrome and VTE, extended anticoagulation is required regardless of bleeding risk 1
• Avoid resuming apixaban given the 2021 CHEST guideline recommendation against DOACs in antiphospholipid syndrome 1

Common Pitfalls to Avoid

• Do not resume apixaban without considering the antiphospholipid syndrome diagnosis and guideline recommendations against DOACs 1, 4
• Do not discharge without ensuring adequate anticoagulation levels and infection control 1, 2
• Do not fail to arrange hematology follow-up within 24-72 hours if early discharge is considered 1, 2