Examkin

Question

Difficulty: EasyPharmacologic Interventions

A 62-year-old woman is evaluated in the emergency department for right lower extremity swelling and pain that began 2 days ago. Her past medical history is significant for hypertension, type 2 diabetes mellitus, and end-stage renal disease requiring hemodialysis three times a week. Vital signs include a temperature of 37.1°C (98.8°F), blood pressure of 142/86 mmHg, pulse of 88/min, and respiratory rate of 14/min. Physical examination reveals a swollen, tender, and erythematous right calf. A comprehensive metabolic panel is notable for a blood urea nitrogen of 42 mg/dL and a serum creatinine of 5.8 mg/dL. Compression ultrasonography of the right lower extremity demonstrates a noncompressible right popliteal vein. Which of the following is the most appropriate initial pharmacologic intervention for this patient?

  1. Intravenous unfractionated heparinAnswer
  2. B
    Subcutaneous enoxaparin
  3. C
    Subcutaneous fondaparinux
  4. D
    Oral dabigatran
  5. E
    Oral warfarin

Answer

Intravenous unfractionated heparin
The correct intervention is intravenous unfractionated heparin. This patient has an acute deep vein thrombosis (DVT) and requires immediate systemic anticoagulation. Because she has end-stage renal disease (ESRD) on hemodialysis, medications that are primarily cleared by the kidneys are contraindicated due to the risk of drug accumulation and severe bleeding. Unfractionated heparin undergoes hepatic metabolism and reticuloendothelial clearance, making it the preferred and safest initial parenteral anticoagulant for patients with a creatinine clearance of less than 30 mL/min.

Step-by-Step Solution

1
Diagnose the acute condition based on clinical presentation and ultrasound findings.
The patient has an acute right popliteal deep vein thrombosis (DVT).
Swelling, pain, erythema, and a noncompressible vein on compression ultrasonography are diagnostic of an acute DVT.
2
Identify significant comorbidities that affect pharmacologic management.
The patient has end-stage renal disease (ESRD) on hemodialysis.
Renal failure alters the clearance of many common anticoagulants, necessitating alternative selections.
3
Select the appropriate anticoagulant that is safe for immediate use in ESRD.
Intravenous unfractionated heparin is selected.
Unlike low-molecular-weight heparins or certain direct oral anticoagulants, unfractionated heparin is hepatically cleared and safe to use in patients with severe renal impairment.

Key Concept

Selection of safe initial anticoagulation in patients with end-stage renal disease
Rate this question

Topics

Pharmacologic Interventions

More questions from this topic