A 60-year-old, female, bilateral leg amputee has diagnoses including PVD, diabetes, COPD, and history of CVA. She is residing
in a nursing home with 100% G-tube feeding and is dependent on a tracheostomy artificial respirator. In a recent hospital
visit for a CVA she was given heparin IV and was discharged with SC Heparin 5000 units three times daily. The only other
significant medications included insulin, metoprolol 25mg bid, and Combivent inhaler tid. The nursing home continued the
heparin for more than three months and no bleeding complications were observed. No laboratory data were available for a baseline
PTT from the hospital. No signs of other complications or thrombocytopenia were evident. How long can heparin be given at
this SC dose without any coagulation monitoring and, if she is not a candidate for warfarin, what are the other alternatives?
Key
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In this case, the patient has the continuing DVT risk factors of immobility and respiratory disease that warrant prophylaxis.
The heparin 5000 units SC TID dose is appropriate and can be given long term if the DVT risk continues, which it will in this
case. Of additional concern is a recent CVA. If this was of cardioembolic origin, then warfarin would be preferred, although
there would be issues with control and monitoring in this patient's case. If the patient is non-cardioembolic, then aspirin
81 mg daily would be recommended for CVA prophylaxis. LDUH is not sufficient for CVA stroke prophylaxis, and not recommended
by the ACCP Consensus Guidelines. In this patient, the combination of LDUH and daily ASA is warranted. Due to the addition
of the daily ASA, we recommend getting a baseline CBC (including PLT count) so that monitoring can be performed to track changes
in PLT and H/H. There is still a small risk of HIT with the long term use of LDUH, so routine PLT monitoring (i.e., CBC)
at least every three to six months would be warranted.
Nancy L. Shapiro, Pharm.D., BCPS
Aimee Chevalier, Pharm.D.
Clinical Pharmacists, Antithrombosis Clinic
Clinical Assistant Professor, Dept. of Pharmacy Practice
University of Illinois at Chicago College of Pharmacy
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