Management of refractory venous thrombosis associated with malignancy using a supra-therapeutic enoxaparin regimen

For many years, it has been recognised that venous thrombo-embolism (VTE) represents a common complication of malignancy. Moreover, VTE in the form of pulmonary embolism (PE) is life-threatening, and constitutes the second leading cause of death in patients with cancer. Consequently, overall survival is significantly reduced in cancer patients who develop thrombosis. In addition, treatment of VTE with anticoagulation is often difficult to manage in the context of cancer. Studies have shown that the risk of recurrent VTE, and the risk of major bleeding are both increased significantly in cancer patients on therapeutic anticoagulant therapy. In this case report, we describe a patient with metastatic carcinoma of the cervix, who developed recurrent thrombotic complications despite being maintained on standard therapeutic doses of both warfarin, and subsequently low molecular weight heparin. However, her refractory VTE was successfully managed using a supra-therapeutic dose low-molecular-weight-heparin (LMWH) regimen, together with close monitoring of plasma anti-Xa levels.