Deep vein thrombosis (DVT) occurs when a blood clot is formed in a vein located deep inside the body

[1]

and usually affects the large veins in the lower legs and thighs. Blood clots are
[2]

produced through haemostasis

. In the treatment of DVT for JL, enoxaparin and warfarin was

prescribed. Enoxaparin, a Low Molecular Weight Heparin (LMHW) is a fragment of Unfractionated Heparin (UFH) is of advantages that it has predictable anticoagulation response, improved subcutaneous (SC) bioavailability, dose-independent clearance, longer biological halflife, lower incidence of thrombocytopenia and less need for routine laboratory monitoring [3]. On contrary, Warfarin is an anticoagulant, or more precisely a vitamin K-dependent coagulation factor inhibitor that comes under the trade names Coumadin and Jantoven [1,4,5]. In case of JL, Enoxaparin is an anticoagulant, or more precisely a low molecular weight heparin under the trade name Lovenox pathway of haemostasis
[2,7] [1,6]

. It blocks particular coagulation factors in the intrinsic

. Its uses are listed below [6]:

1) Treat deep vein thrombosis in patients that are seriously immobilized, due to either surgery or acute diseases [6]. 2) Treat severe deep vein thrombosis (inpatient and outpatient) regardless of the presence or absence of pulmonary embolism [6]. It is utilized together with warfarin [6]. Enoxaparin should be given 1 mg/kg subcutaneously every 12 hours or 1.5mg/kg every 24 hours for JL as he is 55 years old until oral anticoagulant is established. However, routine laboratory monitoring is unnecessary. PT and aPTT are minimally affected by enoxaparin. Prior to initial therapy, a baseline complete blood cell count (CBC) with platelet count and serum creatinine should be obtained. The CBC should be checked every 5 to 10 days during the first 2 weeks of enoxaparin therapy and every 2 to 4 weeks thereafter to monitor for occult bleeding. Warfarin was also prescribed to JL as an anticoagulant agent. Warfarin antagonizes Vitamin K
which is vital for the flawless functioning of hemostasis as it is required for the synthesis of coagulation factors II, VII, IX,X and anticoagulant proteins C and S [2,10]. Warfarin was given concurrently with

enoxaparin. The actions of warfarin will commerce after 48 hours. A lower initial dose should be given to decrease the risk of bleeding especially in JL as he is 55 years old. This is due to age correlates with increased sensitivity towards oral anticoagulants. The usual adult dose of

warfarin is 5mg/day for 2-4 days, followed by 2-10 mg/day as indicated by the measurements of the INR. PT and aPTT was not used as its result will vary from one lab to another. The normal range for one lab would be different than a normal value from another lab, creating problems for patients who were being treated in several locations. In order to standardize the results between labs, the INR was created and must be used for JL. The INR result should be the same, regardless of the location where the tests are performed. Table: Recommendations for initiation and maintenance of Warfarin therapy Initiation of Warfarin (Coumadin) 5 mg Nomogram Day 1 2 or 3 <1.5 1.5 - 1.9 2-2.5 mg > 2.5 4 <1.5 1.5 - 1.9 2-2.5 mg 2.5 - 3 >3 5 <1.5 1.5 - 1.9 2-3 >3 6 <1.5 1.5 -1.9 2 -3 >3 INR Dosage 5 mg** 5 mg 2.5 mg 1- 2.5 mg 0 mg 5 -10 mg 2.5 -5 mg 0 -2.5 mg 0 - 2.5 mg 0 mg 10 mg 5 -7.5 mg 0 -5 mg 0 mg 7.5 -12.5 mg 5 -10 mg 0 - 7.5 mg 0 mg

Maintenance of Warfarin (Coumadin) Based on a therapeutic INR 2-3 INR <1.1 Weekly dose change Consider reinitiation

1.1- 1.2

Consider increasing weekly dose by 10 -20 %

23

Maintain same dose

3 3.9

Consider decreasing weekly dose by 10-20 %

>4

Consider holding a dose and decreasing weekly dose by 20%

The warfarin dose should be adjusted according the INR test readings in order to prevent further complications like profound bleeding. Since JL has developed DVT for the first time due to transient immobilizatio during work, the recommended duration of tratment is 3-6 months. Before administering warfarin to JL, the following considerations must have been taken [8]: 1) Allergies to warfarin or other drugs [8]. 2) The current consumption of drugs, as some drugs may either contain warfarin or will interact with it [8]. 3) The current consumption of herbal products, as they may influence the bodys response to warfarin [8].

4) The medical history and any current illnesses [8]. 5) Alcohol consumption [8]. Warfarin cannot be taken together with alcohol [8]. 6) Future scheduled surgeries [8]. Patients cannot be on warfarin if they are going for surgery [8]. Before administering enoxaparin to JL, the following considerations must have been taken [6,9]: 1) The presence of any bleeding disorders [6]. 2) Allergies to enoxaparin, heparin, pork products or other drugs [9]. 3) The current consumption of drugs [9]. 4) The medical history and any current illnesses [9].

Reference 1. David C. Dugdale, David Zieve (2011). Deep venous thrombosis. Source; http://www.nlm.nih.gov/medlineplus/ency/article/000156.htm. Date accessed 20 February 2012. 2. Anon (2012). Hemostasis. Source: http://faculty.ucc.edu/biology-potter/hemostasis.htm. Date accessed 20 February 2012. 3. Barbara G. Wells, Joseph T. Dipiro, Terry L. Schwinghammer and Cecily V. Dipiro. Pharmacotherapy Handbook
4. Anon (2012). Product Labeling, COUMADIN - warfarin sodium tablet Bristol-Myers Squibb Pharma Company. Source: http://www.pdr.net/drugpages/productlabeling.aspx?mpcode=10450488. Date accessed 20 February 2012. 5. Anon (2012). Concise Monograph, Coumadin (warfarin sodium) Bristol-Myers Squibb. Source: http://www.pdr.net/drugpages/concisemonograph.aspx?concise=374. Date accessed 20 February 2012. 6. Anon (2012). Product Labeling, LOVENOX - enoxaparin sodium injection sanofi-aventis U.S. LLC. Source: http://www.pdr.net/drugpages/productlabeling.aspx?mpcode=73081210. Date accessed 20 February 2012. 7. Anon (2012). Can someone explain PTT, aPTT, and INR? Source: http://allnurses.com/nursingstudent-assistance/can-someone-explain-138282.html. Date accessed 20 February 2012. 8. Anon (2010). Warfarin. Source: http://www.nlm.nih.gov/medlineplus/druginfo/meds/a682277.html. Date accessed 20 February 2012. 9. Anon (2010). Enoxaparin Injection. Source: http://www.nlm.nih.gov/medlineplus/druginfo/meds/a601210.html. Date accessed 20 February 2012. 10. Jon D. Horton, Bruce M. Bushwick (1 February 1999) Warfarin Therapy: Evolving Strategies in Anticoagulation. Am Fam Physician, 59(3) 635-646.

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