AACE Clinical Case Rep.

10 (2024) 261e263

Clinical Case
Reports TM

www.aaceclinicalcasereports.com

Case Report

Extensive Deep Vein Thrombosis in a Young Man Taking Tirzepatide

for Weight Loss
Mohammed Fareeduddin Farooqi, FRCP 1, Muhammad Arshad Mehmood, FRCP 1,
Maria Khan, MBBS 1, Hafiz Muhammad Salman, Pharm D. 2, Adnan Agha, FRCP 3, *
1
Department of Internal Medicine, Tawam Hospital, Al Ain, United Arab Emirates
2
Pharmacy Department, Tawam Hospital, Al Ain, United Arab Emirates
3
Department of Internal Medicine, College of Medicine & Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates

a r t i c l e i n f o a b s t r a c t

Article history: Background/Objective: Obesity and rapid weight loss are risk factors for developing deep vein
Received 14 June 2024 thromboses (DVTs). Our aims were to present a patient who developed extensive DVT after relatively
Received in revised form rapid and severe weight loss that followed taking tirzepatide and to raise the awareness among
22 August 2024 health care professionals regarding the risk of DVT that can be associated with significant weight loss
Accepted 30 August 2024 due to these agents.
Available online 5 September 2024 Case Report: We present the case of a 20-year-old young man, with raised body mass index of >35 kg/
m2, who was initiated on tirzepatide treatment for weight loss, with 12-kg weight lost over 6 weeks.
Key words: The patient did not have any risk factors for thrombophilia including family history, any recent travel,
tirzepatide immobilization, recent infections, or recent surgeries. He presented with left leg swelling, and
deep vein thrombosis physical examination revealed signs of proximal DVT, and ultrasound Doppler and computed to-
glucagon-like peptide-1 receptor mography venography confirmed extensive left-sided DVT with complete obstruction of the com-
agonist mon femoral and iliac veins. He underwent mechanical thrombectomy and was maintained on
anticoagulation therapy. His investigations for thrombophilia screening excluded any other cause for
DVT, with the etiology attributed to possibly rapid weight loss.
Discussion: Newer and potent glucagon-like peptide 1 receptor agonists like tirzepatide are
commonly used nowadays to induce weight loss in obese patients.
Conclusion: Adequate risk assessments and close monitoring should be performed in patients initi-
ating glucagon-like peptide 1 receptor agonists, particularly if they have risk factors for developing
venous thromboembolism.
© 2024 AACE. Published by Elsevier Inc. This is an open access article under the CC BY license (http://
creativecommons.org/licenses/by/4.0/).

Introduction triad, encompassing venous stasis, vascular injury, and hyperco-

agulability.2 Common risk factors for DVT include local infection,
Venous thromboembolism (VTE) affects approximately 5% of external compression, trauma, medications such as estrogen-con-
the population in their lifetime, manifesting as 2 primary condi- taining drugs, immobilization, recent surgery, obesity, and inheri-
tions: (1) pulmonary embolism (PE) and (2) deep vein thrombosis ted conditions such as antiphospholipid syndrome, with more than
(DVT). DVT constitutes the predominant presentation in nearly two 95% of DVT cases occurring in the lower limbs. Lower limb DVTs
thirds of VTE cases, and its incidence and prevalence have steadily typically originate in the calf, with approximately three fourths
increased worldwide in recent decades.1 The pathophysiology of resolving spontaneously; however, 25% progress to involve the
VTE, along with the predisposing factors, aligns with the Virchow proximal leg veins, where nearly half of these cases can embolize,
leading to PE.3 Patients with identifiable risk factors for PE are
labeled as provoked PE, whereas others are termed as unprovoked
Abbreviations: DVT, deep vein thrombosis; GLP1-RA, glucagon-like peptide 1 PE, and these patients may require further workup including
receptor agonist; PE, pulmonary embolism; VTE, venous thromboembolism. testing for thrombophilia and/or screening for malignancy.3,4
* Address correspondence to Dr Adnan Agha, Department of Internal Medicine,
Despite recent technologic advancements, PE remains the third
College of Medicine & Health Sciences, United Arab Emirates University, PO Box
15551, Al-Maqam District, Al Ain, Abu Dhabi State, United Arab Emirates. most common cardiovascular disease globally and one of the
E-mail address: adnanagha@uaeu.ac.ae (A. Agha). leading causes of mortality and morbidity, with even higher

https://doi.org/10.1016/j.aace.2024.08.011
2376-0605/© 2024 AACE. Published by Elsevier Inc. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
M.F. Farooqi, M.A. Mehmood, M. Khan et al. AACE Clinical Case Rep. 10 (2024) 261e263

mortality among the elderly and patients with associated comor-

bidities especially cancer, with a 1-year fatality rate after VTE Highlights
approaching 23.0% in a recent study.4
Our case report describes of a young man who developed  There is an increased risk of deep vein thromboses associ-
extensive left leg DVT after being initiated on glucagon-like peptide ated with obesity
1 receptor agonist (GLP1-RA) to facilitate weight loss.  Glucagon-like peptide 1 receptor agonists can cause rapid
weight loss
 Rapid weight can increase risk of deep vein thromboses
Case Report
 Risk assessment should be performed before initiating these
agents
A 20-year-old young man presented to the emergency depart-
ment with a 3-day history of pain and swelling in his left leg. He
Clinical Relevance
described the pain as sharp, rating 7 out of 10 in intensity, with
radiation to the thigh and back. He reported no history of trauma or The incidence of obesity is increasing, and its treatment options
any family history of thromboembolism. Recently, he had started including glucagon-like peptide 1 receptor agonists may be
Mounjaro (tirzepatide) on a private prescription, taking 7.5 mg dispensed without medical indication or prescription, which
weekly, with the intention of losing weight to meet the physical may lead to serious side effects. Both obesity and rapid weight
requirements for selection in security services. Over the past 3 loss are related to increased risk of deep vein thromboses. This
weeks, he had lost 10 kg. His medical history included glucose-6- case report emphasizes the need for venous thromboembolism
phosphate dehydrogenase deficiency and childhood asthma, for
risk assessment in patients starting on glucagon-like peptide 1
which he did not require any regular medication. He had been
receptor agonists.
previously admitted several times for low back pain secondary to
lumbar disc prolapse (confirmed by magnetic resonance imaging),
managed with analgesia, resulting in complete resolution of
twice daily) during hospitalization, subsequently switching to oral
symptoms.
anticoagulation with edoxaban 60 mg once daily upon discharge.
Upon examination, he was in no apparent distress, and his vital
Given the unprovoked extensive DVT, further investigations
signs including pulse rate and blood pressure were within normal
including thrombophilia screening was sent during admission
limits. His chest was clear, and there were no cardiac murmurs
(results shown in Table 2). The patient was discharged and has
heard. No palpable abdominal masses or abdominal tenderness
was noted. His left thigh exhibited swelling, tenderness, and mild
redness, with a left mid-thigh circumference of 33.5 cm compared Table 1
with 30.5 cm (a difference of 3 cm) on the right side. Additionally, Results of Patient Investigations
the left calf was swollen, measuring 2 cm larger than the right. Investigations Results Normal range
Lower limb venous Doppler studies confirmed extensive DVT
Sodium 136 mmol/L 136-145 mmol/L
involving the left common iliac, external iliac, common femoral,
Potassium 3.4 mmol/L 3.2-5.5 mmol/L
superficial femoral, popliteal, posterior tibial, and great saphenous Creatinine 51 mmol/L 62-106 mmol/L
veins (Fig.). Table 1 summarizes initial laboratory investigations of Urea 2.83 mmol/L 2.80-8.10 mmol/L
the patient. Other investigations for hepatitis B, hepatitis C, and Fasting glucose 4.9 mmol/L 3.9-5.5 mmol/L
viral hepatitis delta screen were all negative. Calcium corrected 2.37 mmol/L 2.10-2.60 mmol/L
Because of the extensive thrombosis extending into the left Magnesium 0.73 mmol/L 0.66-1.07 mmol/L
common iliac vein, the vascular surgery team was consulted. The Albumin 26 g/L 35-52 g/L
patient underwent thrombolysis via interventional radiology using Total bilirubin 15 mmol/L <21 mmol/L
Direct bilirubin 10 mmol/L <5 mmol/L
alteplase followed by mechanical thrombectomy, resulting in the
Alkaline phosphatase 82 IU/L 40-129 IU/L
restoration of blood flow in the left common femoral and great
Aspartate aminotransferase 112 IU/L <40 IU/L
saphenous vein. Echocardiography revealed normal findings Alanine aminotransferase 114 IU/L <41 IU/L
without any evidence of right ventricular strain pattern, and blood Creatine kinase 403 IU/L 39-306 IU/L
cultures were negative. Anticoagulation therapy was initiated with Total cholesterol 4.5 mmol/L 3.90-5.20 mmol/L
subcutaneous low-molecular-weight heparin (enoxaparin 1 mg/kg LDL cholesterol 2.81 mmol/L <2.59 mmol/L
HDL cholesterol 0.96 mmol/L 1.10-1.60 mmol/L
Triglycerides 1.67 mmol/L 0.50-1.70 mmol/L
HbA1c 4.5% 4.3%-5.6%
(26 mmol/mol) (23-38 mmol/mol)
Probrain natriuretic peptide 20.7 ng/L 0-85 ng/L
Troponin 7.9 ng/L <14 ng/L
White blood cell 8.4
109/L 4.5-13
109/L
Hemoglobin 11.5 g/dL 13.2-17.3 g/dL
MCV 78 fL 80-99 fL
MCH 26 pg 27-34 pg
Platelets 332
109/L 140-400
109/L
Prothrombin time 12.8 s 11-13.5 s
INR 1.15 <1.1
APTT 32 s 21-35 s
Fibrinogen level 1.18 g/L 1.50-3.8 g/L

Abbreviations: APTT ¼ activated partial thromboplastin time; HbA1c ¼ glycated

hemoglobin; HDL ¼ high-density lipoprotein; INR ¼ international normalized ratio;
Fig. Left thigh ultrasound showing clot (white arrow) in the left external iliac vein. EIV, LDL ¼ low-density lipoprotein; MCH ¼ mean corpuscular hemoglobin; MCV ¼ mean
external iliac vein. corpuscular volume.

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M.F. Farooqi, M.A. Mehmood, M. Khan et al. AACE Clinical Case Rep. 10 (2024) 261e263

Table 2 increase the incidence of gastrointestinal side effects such as diar-

Results of Thrombophilia Screening of the Patient rhea and the risk of dehydration. Despite both dehydration and
Investigations Results Normal range morbid obesity being well-recognized risk factors for VTE,
Factor V Leiden screen 0.96 0.18-1.13 comprehensive evaluation for other VTE risk factors in these pa-
Factor VIII 474% 50%-200% tients is often overlooked when initiating GLP1-RA treatment.
Factor X 110% 70%-120% Our case serves to alert practitioners about the signs and
Antithrombin III 90% 81.3%-133% symptoms of DVT that should be monitored upon starting GLP1-RA
Protein C activity 136.6% 68.3%-143.5% therapy. The precise mechanism responsible for the increased risk
Free protein S 82 63-115 of DVT, whether attributed to rapid weight loss induced by these
D-dimer 35 000 mg/L 0.124-0.523
agents or dehydration resulting from gastrointestinal side effects,
Cardiolipin IgG 83.8 CUa <20 CU
remains unclear. However, this uncertainty should be explained to
CRP 66 mg/L <5 mg/L
B2 glycoprotein IgG 15.2 CU <20 CU
patients, and a standard risk assessment, including past medical
B2 glycoprotein IgM 1.1 CU <20 CV and family history of VTE and medication history, should be con-
ducted before initiating GLP1-RA treatment. After starting GLP1-RA
Abbreviations: CRP ¼ C-reactive protein; IgG ¼ immunoglobulin G; IgM ¼ immu-
noglobulin M.
treatment, the patients who develop rapid weight loss should be
a
Raised cardiolipin immunoglobulin G antibodies may suggest a possible anti- monitored closely for side effects.
phospholipid syndrome, however a single value is not diagnostic.

Statement of Patient Consent

remained symptom-free for 4 months on outpatient follow-up. The
initial thrombophilia screening results were inconclusive, with Informed consent was obtained from the patient ethical
anticardiolipin immunoglobulin G antibodies levels being elevated. approval was taken from Tawam Hospital Human Research Ethics
The patient is scheduled for repeat thrombophilia testing follow-up Committee with approval number MF2058-2023-993.
with hematology outpatient clinic after completing 6 months of
anticoagulation therapy.
Disclosure

Discussion
The authors have no conflicts of interest to disclose.

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