Board Review: Internal Medicine
62 year old female PMHx HTN and DM presents to the ED with two weeks of worsening left leg swelling. Pain is 8/10 and described as “achy”. Worse with ambulation. Tried tylenol with no relief. Vital signs are within normal limits. Labs show Na 136, K 3.8, Cl 100, HCO3 24, Creatinine 1.7, GFR 28, Glucose 225, Hgb 12, Platelets 215, INR 1.1. Lower extremity duplex shows partially occlusive thrombus in the femoral vein. What is an indication for admission in this patient?
A. Blood Glucose- 225
B. INR 1.1
C. Location of DVT
D. Renal function
Answer: D- Renal Function
Patients with GFR <30 are not candidates for DOACs or low-molecular weight heparins.
Deep venous thrombosis is a very common diagnosis in the Emergency Department. The decision to discharge or admit a patient with a new DVT depends on many different factors. Patients that are hemodynamically stable, have a low risk for bleeding, no renal insufficiency, and are reliable to be closely monitored in an outpatient setting can be discharged from the hospital. Another important consideration is the cost of the medication and if their insurance will cover the medication. Patients should be strictly advised to return to the ED immediately if they are having any difficulty obtaining their medications.
The two most common options for outpatient anticoagulation are rivaroxaban (Xarelto) and apixaban (Eliquis). It is important to initiate therapy in the ED to cover patients until they are able to pick up their medication from the pharmacy. Another option would be to start patients on low molecular weight heparin to bridge to another medication such as coumadin, dabigatran, or edoxaban. However, these regiments need to be very closely monitored in the outpatient setting.
Some important reasons to admit these patients include pain control, lack of outpatient follow up, or lack of insurance. Massive DVTs located in the ileofemoral region should be admitted for a continuous heparin infusion. Patients with concurrent symptomatic PEs as well. Any patient that is high-risk for bleeding or has comorbid conditions requiring hospitalization should also be admitted. In the case above, our patient has poor renal function and is not a candidate for the traditional outpatient regiments. She requires hospitalization for IV heparin and can be bridged to an oral medication such as warfarin.
Kline, J. A. (2016). Section 7: Cardiovascular Disease, Chapter 56: Venous Thromboembolism. In Tintinalli's emergency medicine: A comprehensive study guide (8th ed., pp. 390-399). New York, NY: McGraw Hill Education.
Walling, A. D., MD. (2005). Deciding on Hospitalization for Patients with DVT. American Family Physician,72(9), 1845-1846.