I am asking for my dad. He is 75-year-old, has diabetes for 30 years, no high BP, but has had MI, CABG 14 years back (attached the summary). He was diagnosed with COVID on the fourteenth of this month, mild case, no fever, just cough. His CT has 2/25. He was monitored and discharged on the twenty-first of this month. We did a repeat blood work as it is now 14 days, his values look normal, but I do notice D-dimer is 0.49 ug/mL (upper limit: 0.5 ug/ml). But during discharge at the hospital, it was 72 ng/ml (reference limit is 250 ng/ml). His current WBC is normal, RBC normal, CRP is 1.47, LDH is 197 U/L, and platelets is 296000.
My question, his D-dimer has increased. Does he need a blood thinner? He is taking Clopidogrel 75 mg, but his report says he has a gene defect, CYP2C19. So he only partially metabolizes Clopidogrel so that it can be less effective than usual. Does he need any more treatment with an extra blood thinner? I have attached his medical summary and latest blood work. Also, he was vaccinated with two doses of Covishield. Kindly give your opinion.
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I have gone through your father's reports and health summary (attachments removed to protect the patient's identity). I found that two reports of D-dimer are in different units, one in nanogram (ng) and one in microgram (ug). Both reports are normal. For prevention, I suggest adding an oral anti-coagulation drug, but as he had a history of hemorrhage and D-dimer is normal so we can wait and watch for any symptom.
With COVID, we are prescribing anti-coagulation because it is causing clot formations in lung circulation known as pulmonary thromboembolism (PTE). PTE signs will be a drop in oxygen saturation. So monitor oxygen saturation and any symptoms of uneasiness, increased heart rate (palpitations).
If these symptoms are there, we can do:
1) Repeat D-dimer and CRP (C-reactive protein).
2) Echocardiogram. It can diagnose PTE to some extent.
3) If an echocardiogram is suspecting PTE, then CT (computed tomography) pulmonary angiogram is a confirmatory test.
Tablet Rivaroxaban 10 mg once a day is preventive for any clots but does have bleeding risk. For mild COVID with hemorrhage history, we will add this if D-dimer is deranged and any drop in O2 saturation. Monitor SpO2 (oxygen saturation) daily, six-hourly.
I hope this was helpful.
It is already past 14 days since his initial COVID test. He appears normal, and we just did the test because it is 14 days. He is taking Clopidogrel (but his report says it is less effective). Should we start with a lower dose of additional anticoagulant then? When should we repeat the D-dimer test? Also, is it common for patients to have higher D-dimer even post-COVID? Kindly give your opinion.
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Though there are insufficient data and studies as this is a new disease, people also have complications in moderate and severe cases after months. I suggest you add 10 mg once daily of Rivaroxaban for a month (benefits outweigh over risk). D-dimer can be repeated if saturation drops. Always ask him any odd symptoms he feels (like giddiness, breathing difficulty, chest pain, etc.). Generalized weakness, increase heart rate (to some extent) is common after months post-COVID. Additionally, if there is no contraindication, Clopidogrel can be replaced by Aspirin 81 mg or 75 mg.
I hope this was helpful.
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