Overview of the Triple Challenge: Anticoagulant Therapy in Concurrent

Jafari, Shima; Azdaki, Nahid; Raeesi, Vajehallah; Kazemi, Toba K

doi:doi:10.34172/jept.1781

Overview of the Triple Challenge: Anticoagulant Therapy in Concurrent "Colorectal Cancer, Thromboembolism, Renal Failure": a case report

Document Type : Case Report

Authors

Shima Jafari ¹

Nahid Azdaki ²

Vajehallah Raeesi ³

Toba K Kazemi ⁴

¹ Department of Clinical Pharmacy, School of Pharmacy, Cardiovascular Diseases Research Center, Birjand University of Medical Sciences, Birjand, Iran.

² . Department of Cardiology , Faculty of Medicine, Cardiovascular Diseases Research Center,Birjand University of Medical Sciences, Birjand, Iran.

³ Department of Internal Medicine, School of Medicine, Cardiovascular Diseases Research Center, Birjand University of Medical Sciences, Birjand, Iran

⁴ 12-lead ECG changes after one month of hospitalization for COVID‐19 infection

https://doi.org/doi:10.34172/jept.1781

Abstract

Introduction: The management of anticoagulation in patients with gastrointestinal cancer is complicated by the elevated risk of bleeding, which is amplified by concomitant renal failure affecting the pharmacokinetics of anticoagulant drugs. This case report illustrates the complexities of selecting a safe and effective anticoagulant regimen in this high-risk scenario.
Case Presentation: A 77-year-old male patient with a history of colorectal cancer and chronic kidney disease (creatinine level 2.3 mg/dL) presented with acute dyspnea. Doppler ultrasound confirmed deep vein thrombosis in the left femoral vein. Due to renal impairment, computed tomography pulmonary angiography was contraindicated; a ventilation-perfusion (V/Q) lung scan was performed instead, which diagnosed pulmonary embolism. The primary dilemma was selecting an appropriate anticoagulant that could balance the high risk of recurrent thromboembolism against the heightened risks of drug accumulation and catastrophic gastrointestinal bleeding.
The selection of the therapeutic regimen required a multidisciplinary evaluation involving cardiology, nephrology, and clinical pharmacy experts. To mitigate the risk of drug accumulation while ensuring efficacy, subcutaneous enoxaparin was initiated at a renal-adjusted dose of 60 mg subcutaneously once daily. This approach aimed to provide effective treatment for cancer-associated thrombosis while carefully monitoring the patient’s clinical status in the setting of severe renal impairment.
The patient was discharged on this regimen and completed a full 6-month course of enoxaparin without any thromboembolic or bleeding complications. At the 9-month follow-up, the patient remains asymptomatic and off anticoagulants. Based on recent colonoscopy findings showing no active disease or residual mass, the patient requires no further surgical intervention or anticoagulant therapy, demonstrating an excellent clinical outcome.
Conclusion: This case underscores the need for a tailored, multidisciplinary approach to anticoagulation in patients with gastrointestinal cancer, thromboembolic disease, and renal insufficiency. Low-molecular-weight heparin (LMWH), alongside careful dose adjustment and continuous monitoring, represents a viable therapeutic option in this complex patient population.

Keywords

Colorectal neoplasms

Venous thromboembolism

Pulmonary embolism

Renal insufficiency

Anticoagulants

Enoxaparin

Subjects

Cardiology

1. Mansori K, Solaymani-Dodaran M, Mosavi-Jarrahi A, Motlagh AG, Salehi M, Delavari A, et al. Spatial inequalities in the incidence of colorectal cancer and associated factors in the
neighborhoods of Tehran, Iran: Bayesian spatial models. J Prev Med Public Health 2018;51(1):33-40. doi:10.3961/jpmph.17.167
2. Tatsumi K. The pathogenesis of cancer-associated thrombosis. Int J Hematol 2024;119(5):495-504. doi:10.1007/s12185-024-03735-x
3. Bazarbashi S, El Zawahry HM, Owaidah T, AlBader MA, Warsi A, Marashi M, et al. The role of direct oral anticoagulants in the treatment of cancer-associated venous thromboembolism:
review by middle East and North African experts. J Blood Med 2024;15:171-89. doi:10.2147/jbm.S411520
4. Montomoli M, Candía BG, Barrios AA, Bernat EP. Anticoagulation in chronic kidney disease. Drugs 2024;84(10):1199-218. doi:10.1007/s40265-024-02077-6
5. Khorana AA, Mackman N, Falanga A, Pabinger I, Noble S, Ageno W, et al. Cancer-associated venous thromboembolism. Nat Rev Dis Primers 2022;8(1):11. doi:10.1038/s41572-022-00336-y
6. Fernandes CJ, Morinaga LT, Alves JL Jr, Castro MA, Calderaro D, Jardim CV, et al. Cancer-associated thrombosis: the when, how and why. Eur Respir Rev 2019;28(151):180119.
doi:10.1183/16000617.0119-2018
7. Keskin HV, Ozcelik N, Senturk Topaloglu E, Ozyurt S, Gumus A, Sahin U. Which is more valuable in the diagnosis of pulmonary thromboembolism? The wells score, the revised Geneva score, or the Padua score? Life (Basel) 2025;15(7):1115. doi:10.3390/life15071115
8. Lyman GH, Carrier M, Ay C, Di Nisio M, Hicks LK, Khorana AA, et al. American Society of Hematology 2021 guidelines for management of venous thromboembolism: prevention and
treatment in patients with cancer. Blood Adv 2021;5(4):927-74. doi:10.1182/bloodadvances.2020003442
9. Key NS, Khorana AA, Kuderer NM, Bohlke K, Lee AY, Arcelus JI, et al. Venous thromboembolism prophylaxis and treatment in patients with cancer: ASCO guideline update. J Clin Oncol
2023;41(16):3063-71. doi:10.1200/jco.23.00294
10. Key NS, Khorana AA, Kuderer NM, Bohlke K, Lee AYY, ArcelusJI, et al. Venous thromboembolism prophylaxis and treatment in patients with cancer: ASCO clinical practice guideline
update. J Clin Oncol 2020;38(5):496-520. doi:10.1200/jco.19.01461
11. Streiff MB, Holmstrom B, Angelini D, Ashrani A, Buckner T, Diep R, et al. Cancer-associated venous thromboembolic disease, version 2.2024, NCCN clinical practice guidelines
in oncology. J Natl Compr Canc Netw 2024;22(7):483-506. doi:10.6004/jnccn.2024.0046
12. Yhim HY. Proper application of anticoagulation therapy on cancer-associated venous thrombosis. Blood Res 2024;59(1):25. doi:10.1007/s44313-024-00029-3
13. Caruana J, Riva N, Vella K, Davenport A, Gatt A. Navigating through the haemostatic paradox in kidney failure: a practical overview. Br J Haematol 2023;202(2):230-47. doi:10.1111/bjh.18903
14. Parul F, Ratnani T, Subramani S, Bhatia H, Ashmawy RE, Nair N, et al. Anticoagulation in patients with endstage renal disease: a critical review. Healthcare (Basel) 2025;13(12):1373. doi:10.3390/healthcare13121373
15. Damiani A, De Menezes Caceres V, Roberts G, Coddo J, Scarfo N, Willliams DB, et al. A clinical practice-based comparison of conventional and individualized dosing
strategies for therapeutic enoxaparin. Pharmacol Res Perspect 2025;13(1):e70039. doi:10.1002/prp2.70039
16. Corona CM, Melero EL, Triska EL, León M, Roldán D, Gruss E, et al. #2147 Enoxaparin dosing in advanced chronic kidney disease: importance of monitoring with anti-Xa levels. Nephrol Dial Transplant 2024;39(Suppl 1):gfae069-1446- 2147. doi:10.1093/ndt/gfae069.1446