Sometimes Less is Better:
The Treatment of Venous Thromboembolism

MR. CRAMER:

“You want me to take this stuff for the rest of my life? Don’t get me wrong, I’m not trying to give you a hard time, but I don’t like to take medicine every day, and getting my blood drawn for tests every week hasn’t exactly been my favorite thing in the whole world!”

NARRATOR:

When he was 45 years old, Ed Cramer developed a blood clot in the lower part of his left leg, causing his leg to become red, swollen, and to hurt so badly that he could not even walk because of the pain. He spent five days in the hospital, during which time he received treatment with an intravenous medication, heparin, to help control the blood clot. After Mr. Cramer went home, he had to take an oral medication, warfarin, for the next six months to be certain that the blood clot wouldn’t harm him.

During his treatment with warfarin, Ed had to get his blood tested every week or two so that Dr. Springer and Dr. Johnson could monitor the effect of the medication. Sometimes, Dr. Johnson called him after a blood test and instructed him to raise or lower his daily dose of warfarin. These changes sometimes seemed unpredictable. Dr. Johnson explained that many medications and even some foods could change the effect of the body’s processing of warfarin, resulting in a change in its effect. If the dose was too low, his blood might be more likely to clot; if the dose was too high, he might experience abnormal bleeding. There didn’t seem to be a very wide margin for error.

DR. SPRINGER:

“Mr. Cramer, I can appreciate the discomfort and inconvenience of sticking with this treatment, but without it you are at risk for getting another blood clot. I know that you are all too familiar with that and the possible complications.”

MR. CRAMER:

“You don’t have to remind me.”

NARRATOR:

Just one year after finishing treatment for his first blood clot, Mr. Cramer had developed another—this time it nearly killed him. He was at home watching TV when suddenly he had a feeling of pressure in his chest and trouble catching his breath. A large clot had traveled through his bloodstream from a vein in his left leg, where it had formed, to a large blood vessel in his lung. The clot blocked the flow of blood through part of his lung, interfered with oxygenation of the blood, and caused the death of some of his lung tissue. Seeing him immobilized on the couch, his wife Nancy called the paramedics. He was in intensive care for more than a week. It was the most frightening experience of his life. After he was discharged from the hospital, Mr. Cramer had to take warfarin for another six months.

MR. CRAMER:

“This medication is nothing to fool around with either. Do you remember when this medication put me back in the hospital?”

NARRATOR:

Once while on warfarin therapy, Mr. Cramer’s back went out and he began to take ibuprofen regularly for relief of back pain. He did not let Dr. Springer or Dr. Johnson know he was taking the ibuprofen. After approximately two weeks of taking the maximum dose of ibuprofen recommended on the package (six 200mg tablets per day), he noticed that he was regularly passing black, tarry looking stool. He had to go back to the hospital and get a transfusion of two pints of blood to replace the blood that he had lost. He had developed gastritis from taking too much ibuprofen. With his body’s blood clotting system partially disabled by warfarin, this was enough to cause a significant bleed.

Ed felt that smoking had caused his clotting problem. After trying three times, he finally succeeded in kicking the habit. Nearing the end of his second six-month course of treatment with warfarin, he looked forward to getting it over with.

DR. JOHNSON:

“Mr. Cramer, I think that your treatment could be a lot easier than what you’ve been through so far while taking warfarin. A new study has come out showing that treatment with warfarin at a low dose could reduce your risk of having another serious blood clot, with a low risk of causing severe bleeding. So, low dose warfarin treatment would probably be safer than your current treatment. For this reason, you would not need to get your blood tested as often—possibly as infrequently as every two months.”

MR. CRAMER:

“That doesn’t sound too bad, but does it work? I mean, for the last six months I’ve had to get my blood drawn almost once a week and the warfarin is adjusted up and down to get it just right. I’ve had serious blood clots twice. Can this low dose treatment really protect me from getting another one? And what exactly is a ‘low risk’ of severe bleeding? Is this treatment really worth it?”

NARRATOR:

These were good questions and Dr. Springer did not have the answers off the top of her head.

DR. SPRINGER:

“As I said, this study has just recently come out and I haven’t had a chance to go over it in detail. Low dose warfarin may be a good option for you. How about if I get some additional information on the benefits and risks of this treatment and we can go over it at a follow-up visit in one month?”

MR. CRAMER:

“That sounds fine. I’ll be due to come in for a physical, anyway. See you then.”