Every day, pharmacists are placed into situations that require difficult clinical decisions. These cases are usually the ones that take up the most research time, involve most of our energy, and spark debate among other healthcare providers. Read the following case. What would you do? Would you have approached it differently?

A 60 year-old male is admitted to a nursing home. He is unable to walk and wheelchair bound. His past medical history includes paranoid schizophrenia, alcoholism, hypertension, chronic back pain, BPH, and obesity. His current weight is 130 kg (ideal body weight is 67 kg). He regularly takes his medications which include quetiapine, lisinopril, and enoxaparin. Enoxaparin is dosed 40 mg SQ every 12 hours. You notice that the patient has been on the low-molecular weight heparin for the past 3 months with no recent laboratory results. What would you do?

What does the scientific evidence show? 

It’s obvious to you that there are no studies that substantiate long-term use of enoxaparin for deep vein thrombosis (DVT) prophylaxis. Studies have demonstrated that there are variables such as obesity, pregnancy, history of DVT, anti-phospholipid syndrome, and cancer which can contribute to DVT risk. If there are enough risk factors, it would be prudent to start enoxaparin or DVT prophylaxis in these patients. Specifically, when these patients are hospitalized or undergoing major surgery. Current guidelines do not support long-term DVT prophylaxis in outpatients (except if they developed a solid cancer mass and have risk factors or have a history of recurrent DVTs).

Should you raise your concerns with the physician?

Should you approach the physician and remind him of the guidelines? Should you wait another 3 months and see what happens to the patient? This is when your clinical judgment matters the most. You have to think about what happens if you don’t act on this problem. Can the patient suffer severe harm or death from this? Would other pharmacists agree with your decision to abandon the problem? If the patient is at risk and other pharmacists think it’s important to approach the physician, then you need to call the physician.

How should you approach the doctor?

What is the best way to approach the physician? You don’t want to appear condescending or intimidating. Ask to speak to him/her for a moment regarding the patient. Lay down the groundwork by saying, “This patient is on Lovenox 40 mg every 12 hours for 3 months.

” Specify what you want by asking, “I was wondering how long you intend for him to be on this regimen. Can we stop Lovenox?” There is no need to refer to guidelines unless he requests it. Otherwise, you will be portrayed as a condescending pharmacist.

Outcome of the pharmacist's intervention

After he/she hears your plea, they decide not to stop it. They respond sternly, “No. This patient is morbidly obese and has a high risk of DVT. He is wheelchair bound.” What do you do now? At the end of day, you have to ask yourself, “What do I want to accomplish with this recommendation?” You want the best for the patient. You want to minimize adverse effects, major bleeding, and heparin-induced thrombocytopenia. Ask the physician if he would like to order a CBC, just to “make sure everything is okay.” He agrees and the lab is ordered.

Although we are not able to get the medication discontinued, we are able to address the issue. The physician is aware of our concern and the appropriate lab is ordered. The physician is responsible for their clinical decision. He/she may have felt that the risk of DVT is much greater than the risk of side effects. In their defense, a clot in the legs can easily travel to the pulmonary tree and cause pulmonary embolism, which carries a higher mortality risk.

References

Gordon H. Guyatt, Elie A. Akl, Mark Crowther, David D. Gutterman, Holger J. Schuunemann,and for the American College of Chest Physicians Antithrombotic Therapy and Prevention ofThrombosis: Executive Summary: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest.2012;141(2)(suppl):7S-47S.

About the Author

Dr. Karine Wong has a 10 year history of working in hospital management and 2 years as a hospital pharmacist and outpatient pharmacist. She recently published a children's book called Don't Sit on Her.

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