BETA - What are signs and symptoms of a blood clot (Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE)? How are they managed?

What is a deep vein thrombosis and a pulmonary embolism? A DVT stands for deep vein thrombus. These are blood clots that can occur in the deep veins anywhere in the body, but most commonly in the legs or in the lungs. What are signs and symptoms of a blood clot? The symptoms of a deep vein thrombus include things like a new development of pain, particularly asymmetric pain, one leg, a swelling, again asymmetric, redness, that's another thing that can happen, or if it's a DVT in the lungs called a pulmonary embolus, then you may have things like a chest pain or a shortness of breath that started. The classic signs and symptoms of a blood clot, they usually occur in the lower extremities. There's going to be a calf pain, redness or swelling or warmth in an area where there's not another explanation. We really tell all patients if they have a new calf pain or pain in their leg and it feels red and warm, then they need to have an ultrasound right away. Sometimes patients present with thought in their lungs and where maybe they had an unsymptomatic one in their leg and it breaks off and it's called a pulmonary embolus, which is a blood clot in the lungs. That feels like sometimes a sharp pain for people, shortness of breath, their heart's racing when it shouldn't be, and those sorts of patients need to have chest imaging or be evaluated with ultrasound of the extremities and then maybe chest imaging depending. So I wouldn't wait if you have any of those symptoms. It's always better to call and talk your symptoms out with a provider. All patients with malignancy and especially patients with multiple myeloma are at a risk for developing a blood clot. The risk comes from the active malignancy itself, but then also it can happen because of the side effects of treatments. Plus sometimes patients at diagnosis are very sick, not moving around a whole lot and that increases the risk as well. So patients need to be sort of risk stratified as they're met and anybody who has a prior history of a thrombolytic event falls into a higher risk category and needs to be put on therapeutic prophylaxis. Introducing high dose steroids and the imides to patients with myeloma also increases the risk for a blood clot. There is an increased risk of DVTs that happen in many different kinds of cancers. Myeloma is certainly one of them. There are many treatments of myeloma that can contribute to an increased risk of DVT as well. Some of the most common are a class of drugs called imides or immunomodulatory agents. These include things like thalidomide or linalidomide or pomalidomide. These are notorious and quite commonly known for increasing risk of a DVT. Other drugs that can do it are high doses of steroids in combination with drugs like imides or certain chemotherapy agents. And carfilzomib is another medication that also is known to increase the risk of DVT. What should myeloma patients know about prophylactic prevention of deep vein thrombosis while on imides? We commonly use at least a low dose aspirin. This has been found to be quite effective in reducing the risk of DVTs for patients who are on one of these agents. If the patient already has a prior history of DVT, that increases their risk. And so we may want to use some other stronger prophylactics such as pills called DOEX or even a low molecular rate heparin, which are injectables. So there are several different agents now that are helpful in reducing the risk of DVT. Based on a certain risk categorization system, we may assess what the level of risk is in a patient and choose one of these prophylactics. If someone has no other risk factors other than the cancer itself and the therapy they're going to go on, then we typically put people on a daily aspirin and that should be enough. If there's any other reason to think they're at a higher risk for blood clot, then we try to use therapeutic anticoagulation, which historically was a drug called anoxaparin or lovinox. More recently, there's good evidence for using the DOEX as prophylaxis, and that's a lot more convenient for patients. It can be more expensive, so we're always checking drug costs and making decisions based on a bunch of factors. What should patients do if they start experiencing symptoms of a blood clot? They should immediately bring it to the attention of their doctor, the myeloma doctor who's treating them. And since they are most knowledgeable about the medication that the patients are on, that will immediately alert them to order the right tests to look for a blood clot. And the test that we would commonly use would be a duplex scan. It's a kind of ultrasound to look at the veins and see if there's any obstruction, if there's a blood clot in the veins. If an individual notices symptoms over the weekend, should they go to ER? I would definitely not wait until Monday. I would call that after hours number. The reason is that blood clots that start in the legs can migrate and they can go to more dangerous locations like in the lungs and actually make it much worse or even cause a life-threatening event. So it's best to not take that risk call right away and your doctor will direct you to the nearest emergency room or location to investigate this and take care of this soon. If a blood clot is detected, how is it treated? The way we treat it is with blood thinners. Blood thinners come in various forms. Now you can have pills, which are fairly easy to take. There are injectables, so we could do that. So depending on the specific medical condition of the patient, the doctor will choose the best anticoagulant, as they are called. If an individual developed a blood clot during treatment, can they safely go back to the treatment? Yeah, most likely your doctor will temporarily hold these medications while the acute problem of the blood clot is addressed. But there's no contraindication specifically to being able to go back on these medications. This is not a general rule, of course. It depends on how bad the blood clot was. Did you respond to the blood thinner medications, etc.? But it's certainly not a no-no to be able to go back on the original medications. Would an individual at greater risk if they had one blood clot to get another one? In general, having one blood clot does increase the risk for another, but the situation again is very specific as well. Let's say there was someone who were on these medications, but inadvertently was not taking the prophylactics. Well, that obviously increases the risk for having a blood clot, and being on the appropriate medications will decrease the level of that risk back to not much higher than it was initially. So it depends. If on the other hand, they were on adequate prophylaxis and still developed the blood clot, that does mean that their risk for having another one is elevated. Does your risk increase if you are on a higher dosage of an omit? That's a good question. I don't really think we know the answer to that. Steroid doses do seem to be related to the risk. In maintenance after transplants, when linalidamide is used frequently by itself, the risk seems to be overall lower than in the induction phase, but that also may be related to the high tumor burden. So I think that being on one of these agents elevates the risk. I think the highest risk comes from excluding other risk factors that patients may come to the disease with. The highest risk is early on when the cancer, the myeloma is most active, and patients tend to sort of be the sickest or the worst. And most people nowadays are getting an imid up front, and that introduces the biggest risk. During the transplant period, most people, while they're neutropenic, are also thrombocytopenic, so platelets are low because the Malfalene chemotherapy kills all the platelets to be made in the bone marrow, and so the risk for blood clot is not as high at that point in time.