Treatment Failure of DVT and PE During Hospitalization with Lovenox
Joann Lohr, Emily Wright, Amie Jackson.
Trihealth, Cincinnati, OH, USA.
OBJECTIVE- Anticoagulant resistance can be difficult to identify. A high index of suspicion is necessary in patients who do not progress as expected during anticoagulant therapy. We detail the case of a patient with previously unknown heparin resistance.
METHODS - Case study and retrospective review of literature of anticoagulant failures.
RESULTS - We report the case of a 55 year old male who developed an iliofemoral DVT after six weeks of immobilization in a brace for a proximal tibial fracture. The patient is an otherwise healthy smoker with no family history of DVT. He was initially admitted for lovenox and coumadin therapy but after three days he showed no evidence of symptom improvement and progressed to phlegmasia. At this point he was transferred to a larger hospital where he was successfully anticoagulated with heparin. He did require greater than normal levels on his heparin drip, over 2400 units per hour to maintain therapeutic PTT range. A hypercoagulable workup revealed only a MTHFR heterozygous mutation and mildly elevated homocysteine levels.
CONCLUSIONS- With so many options for anticoagulating patients including many which require very little monitoring, it is easy to get complacent. We order a pill or an injection and we assume that the medication is working effectively. However, we forget that there is a subgroup of patients who even in the absence of a known clotting disorder may not respond to therapy. Heparin resistance does occur in the general population even in absence of a diagnosed clotting disorder. To this effect, it is imperative that patients who are started on heparin anticoagulants have a baseline PTT measured. An elevated PTT should raise suspicion that the patient may have resistance to heparin based anticoagulant therapies. Having a baseline value will also allow earlier and more in-depth monitoring for those patients who seem not to be responding as effectively to the treatment or the selection of another method of therapy.
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