ADALIMUMAB (HUMIRA) AND THE RISK OF RECURRENT VENOUS THROMBOEMBOLISM

Abstract

SESSION TITLE: Monday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Anti-TNF alpha agents have increasingly been used to treat several types of auto-immune diseases, including rheumatoid arthritis and Crohn’s disease. Deep vein thrombosis is an uncommon but important side effect of this medication. Optimum duration of anticoagulation therapy is unknown due to lack of large data studies or guidelines.. In this case, we discuss the possible necessity of indefinite anticoagulation for patients taking adalimumab after having a venous thrombotic event. CASE PRESENTATION: A 54 year old African American female with past medical history significant for obesity, uveitis, retinal detachment and rheumatoid arthritis, presented to the ED with generalized fatigue, dizziness, and shortness of breath. She had no other significant cardiac history. She did not have any history of prior deep vein thrombosis or family history of a hyper-coagulable disorder. She had started Adalimumab 4-5 months prior to this visit. Notable vitals included heart rate of 140 and EKG showing atrial fibrillation with no changes indicating ischemia. CXR showed mild pulmonary vascular congestion. She was given diltiazem 20mg IV in the ED and started on diltiazem 30mg PO every 6 hours. CT angiography of the chest revealed bilateral main pulmonary artery emboli, segmental, and subsegmental pulmonary emboli. She was started on tPA via catheter directed thrombolysis for 24 hours and heparin drip. Ultrasound of BLE was significant for non-occlusive deep vein thrombosis (DVT) in right popliteal vein. Patient was discharged on apixaban 10mg BID for 6 days to switch to 5mg BID for 6 months. After 6 months, apixaban was discontinued. Two months after discontinuation of apixaban, she presented to the ED with left calf pain. LLE Venous Duplex was performed and revealed left popliteal DVT. Anticoagulation therapy with apixaban was reinstituted. DISCUSSION: Adalimumab is associated with increased risk of DVT. Since our patient did not have a prior history of DVT, we believed the use of Adalimumab resulted in a hyper-coagulable state. Despite causing a lupus-like syndrome, the true mechanism is unknown. Previous studies discussed that patients with Adalimumab antibodies may have an increased risk of thromboembolic events compared to those without. A subsequent larger study refuted this association. The temporality of events, including recurrence of DVT after discontinuation of anticoagulation therapy strongly suggests possibility of ongoing risk of thromboembolism and need of continued anticoagulation therapy, similar to the patients with other chronic hyper-coagulable states and certain types of cancer. CONCLUSIONS: This case demonstrates the need for evaluation of anticoagulation guidelines in patients taking Adalimumab due to the persistence of hyper-coagulable state after previous thromboembolic events. Reference #1: Korswagen, L. A., Bartelds, G. M., Krieckaert, C. L., Turkstra, F. , Nurmohamed, M. T., van Schaardenburg, D. , Wijbrandts, C. A., Tak, P. P., Lems, W. F., Dijkmans, B. A., van Vugt, R. M. and Wolbink, G. J. (2011), Venous and arterial thromboembolic events in adalimumab-treated patients with antiadalimumab antibodies: A case series and cohort study. Arthritis & Rheumatism, 63: 877-883. https://doi.org/10.1002/art.30209 DISCLOSURES: No relevant relationships by Chinmaya Sharma, source=Web Response