(4.1) ANTICOAGULATION CASE STUDY

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Questions and Answers

What condition was diagnosed in Sandie based on her ultrasound results?

Cellulitis

Venous insufficiency

Atherosclerosis

Deep vein thrombosis (correct)

Which of the following factors is part of Virchow's Triad that contributed to Sandie's condition?

Immobility (correct)

Recent exercise

Increased physical activity

Genetic mutation

What specific genetic condition was found to be positive in Sandie's case?

Protein C Deficiency

Antithrombin III Deficiency

Factor V Leiden (correct)

Prothrombin Gene Mutation

How do estrogen-containing oral contraceptives impact the risk of thrombus formation?

By affecting gene transcription factors Signup and view all the answers

Which of the following is NOT a potential risk factor for thrombus formation in young individuals like Sandie?

High levels of physical activity Signup and view all the answers

Which progestins have been found to increase blood clot risk the most?

Drospirenone and desogestrel Signup and view all the answers

What is the primary treatment for superficial thrombophlebitis?

Warm compress and NSAIDs for pain relief Signup and view all the answers

Which component is part of Virchow's Triad that may lead to thrombus formation?

Endothelial injury Signup and view all the answers

What lifestyle factor can contribute to venous obstruction?

Immobility and prolonged rest Signup and view all the answers

What should be done when treating thrombosis in a patient using estrogen-containing contraceptives?

Discontinue estrogen-containing products immediately Signup and view all the answers

Which is NOT a related factor in the formation of a thrombus?

Low blood pressure Signup and view all the answers

Which condition can lead to an increased risk of venous thrombosis associated with immobility?

Office work without movement Signup and view all the answers

What type of contraceptive is recommended for patients who cannot take estrogen due to thrombosis risk?

Copper IUD or progestin-only methods Signup and view all the answers

Which medical condition is NOT a potential thrombosis risk factor?

Regular exercise Signup and view all the answers

Which of the following describes the primary consequence of a thrombus in the venous system?

Reduced oxygen delivery Signup and view all the answers

What primarily characterizes fibrin-rich clots in the clotting cascade?

They incorporate a large amount of fibrin along with platelets Signup and view all the answers

What role does the prothrombin gene mutation play in thrombus formation?

It increases the production of prothrombin, enhancing clotting. Signup and view all the answers

What distinguishes deep vein thrombosis from superficial vein thrombosis?

Deep vein thrombosis often requires long-term anticoagulation therapy Signup and view all the answers

What is the primary risk associated with the use of anticoagulants compared to anti-platelets?

Anticoagulants are associated with a higher risk of bleeding Signup and view all the answers

How does antithrombin III deficiency affect the body's ability to manage blood clots?

It impairs the body's natural anticoagulant processes, increasing thrombus formation. Signup and view all the answers

How does estrogen-containing birth control impact the risk of thrombus formation?

Estrogen increases factors that lead to clot formation Signup and view all the answers

What is the impact of estrogen-containing contraceptives on the risk of thrombosis?

They increase clotting factors and can elevate the risk of thrombus formation. Signup and view all the answers

Which contraceptive options are recommended for a patient at risk of thrombus formation who can no longer use estrogen-containing products?

Progestin-only pills and progestin IUDs Signup and view all the answers

What distinguishes superficial thrombophlebitis from deep vein thrombosis?

Superficial thrombophlebitis involves inflammation of veins close to the skin's surface, while deep vein thrombosis occurs in deeper veins. Signup and view all the answers

Which component of coagulation disorders was found to be negative in the patient’s genetic testing?

Prothrombin gene mutation. Signup and view all the answers

Study Notes

Anticoagulation Case Study: Riding the Struggle Bus

Course: BMS 551 Med Phys Pharm
Instructor: Brian Skinner, PharmD, BCPS
Institution: Marian University – Wood College of Osteopathic Medicine
Term: Fall 2024

Objectives

Relate patient medical history, diagnosis, and treatment to medical physiology and pharmacology.
Identify risk factors for thrombus development.
Identify contraceptive products contraindicated in patients with hypercoagulable disorders.
Identify steps in fibrin clot formation, including extrinsic, intrinsic, and common pathways.
Examine pregnancy's effect on pharmacotherapy selection and identify appropriate anticoagulants for patients.

Agenda

Clinical Case: Patient presentation, pathophysiology of disease, future issues, treatment of disease.
Conclusion: Impact on student practice. Discussion of learning points.

Patient: Sandie Lynn Kris (18 yo female)

Social History: College freshman, flute player in marching band, not sexually active, denies alcohol, tobacco, illicit drugs.
Past Medical History: Dysmenorrhea, acne.
Medications: Yaz® (ethinyl estradiol & drospirenone).
Travel History: Recent 5-hour bus trip to another college for a football game with the marching band.

Patient Case: Presentation

Chief Complaint: Swelling and pain in left lower extremity.
Imaging: Ultrasound reveals a thrombus in the great saphenous vein of the left leg.
Genetic Testing:
- Prothrombin Gene Mutation: Negative
- Antithrombin III Deficiency: Negative
- Protein C Activity: Normal
- Factor V Leiden: Positive (heterozygous)

Virchow's Triad in Action

Circulatory Stasis: Immobility, venous obstruction (e.g., obesity, pregnancy, tumor), varicose veins, atrial fibrillation.
Endothelial Injury: Trauma, atherosclerosis, venepuncture.
Hypercoagulability: Surgery, malignancy, pregnancy, estrogen therapy, inherited thrombophilia.

Clotting Cascade (Simplified)

Intrinsic Pathway (aPTT): XII, XI, IX, VIII, X.
Extrinsic Pathway (PT): VII, X.
Common Pathway (aPTT & PT): V, II, Fibrin Clot, XIII.

Clotting Cascade (Full)

Includes details of the contact activation and tissue factor pathways, key factors like thrombin, as well as the roles of protein C and protein S.

Birth Control and Thrombus Formation

Estrogen-containing oral contraceptives affect gene transcription factors of proteins (II, VII, X, XII, XIII, and fibrinogen).
Progestins were added to decrease estrogen in OCPs. Drospirenone and desogestrel are novel progestins with antimineralocorticoid and antiandrogenic properties.
Increased blood clot risk by 1.5-fold compared to other progestins.

Venous System of the Legs

Diagram of the superficial and deep venous systems of the legs, including the sapheno-femoral junction and communicating veins.

Treatment

Warm compress of the affected area.
NSAIDs as needed for pain.
Discontinue estrogen-containing oral contraceptives.
Use progestin-only pill, progestin IUD, progestin implant, or copper IUD.

Treatment Plan

Enoxaparin until week 36.
Switched to heparin until week 39.
Planned induction for 39+1 weeks.
Placed back on enoxaparin 24 hours after delivery x 6 weeks.

Medications to Treat Thrombotic Disorders

Injectable Formulations: Heparin Products: heparin, low-molecular-weight heparins (enoxaparin, dalteparin). Factor Xa Inhibitors: rivaroxaban, apixaban, betrixaban, edoxaban, fondaparinux.
Oral Formulations: Direct Thrombin Inhibitors (Factor II): dabigatran, argatroban, bivalirudin. Vitamin K Antagonists: warfarin.

Thromboprophylaxis During Pregnancy

Heparin dosages, route of administration (subcutaneous), half-life, and factors inhibited.
Enoxaparin dosages, route of administration (subcutaneous), half-life, and factors inhibited.
3rd Trimester vs 1st and 2nd Trimester dosing considerations.
Injection site locations.

Impact on Me and My Practice

As a healthcare provider, it can be challenging to be a patient/patient's family member.
Implementation of care is more complex than simply prescribing medication.

What Can We Learn?

Chronic conditions, even without explicit treatment requirements, are still chronic.
Understanding disease pathophysiology is vital to identifying at-risk patients.
Managing conditions during pregnancy adds the challenge of ensuring both maternal and fetal safety and efficacy of therapy.

MPP Patient Podcast Project

Podcast by Tanner Maxfield providing further patient perspective.
URL provided for podcast.

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Description

Explore a clinical case study focused on anticoagulation in BMS 551 Med Phys Pharm. This quiz will guide you through patient medical history, thrombus risk factors, and pharmacotherapy considerations. Analyze the impact of pregnancy on anticoagulant selection and understand fibrin clot formation pathways.

(4.1) ANTICOAGULATION CASE STUDY - DR. SKINNER