25 - Oral Anticoagulants Flashcards
Rivaroxaban
Xarelto
DOSING:
DVT Following Hip or Knee Replacement Surgery
- *CrCL <30 mL/min**
- *AVOID**
- *10mg QD**
- with or without food*
DABIGATRAN = Pradaxa
- *Treatment / Reduction in risk of DVT & PE**
- *DOSING**
Treatment / Reduction in risk of DVT & PE
CrCl >30:
150mg BID after 5-10 days of Parenteral AC “Bridge”
CrCl < 30 or Dialysis
dosing not provided
CrCl <50 + P-gp Inhibitor
AVOID co-admin
Rivaroxaban
Xarelto
DOSING:
DVT or PE Treatment
15mg wf BID x 21 days
then
20mg wf QD
- *CrCl < 30 ml/min**
- *AVOID**
Which AC drug is
CONTRAINDICATED w/ CrCL > 95?
EDOXABAN = Savaysa
Non-Valvular AFIB w/ CrCL > 95
Is
CONTRAINDICATED
Also CrCl < 15
Which AC drug inhibits
Factor Xa?
Rivaroxaban** / **Apixaban** / **Edoxaban
Xarelto / Eliquis / Savaysa
Betrixaban
Which AC drugs require
BRIDGING / Parenteral Lead-In
DABIGATRAN
DVT/PE Treatment –> 5-10 days of Bridge
then 150mg BID (reg dose)
EDOXABAN
DVT/PE Treatment –> 5-10 days LMWH/UFH
then 30mg QD (normal is 60mg)
Dabigatran
Pradaxa
DRUG INTERACTIONS
- *AVOID with Pg-p INDUCERS**
- *Rifampin / Carbamazepine / Phenytoin**
Pg-P Inhibitors
↑Drug Concentration –> ↑Risk of Bleeding
DRONEDERONE** or **KETOKONAZOLE
AFIB:
CrCl 30-50 = 75mg BID, CrCl <30: Avoid
Ortho VTE Prophylaxis:
CrCl >50 = seperate doses by hours, <50 = AVOID
Apixaban
Eliquis
DOSING:
Reduction in risk of recurrent DVT & PE following initial therapy
- *2.5mg BID**
- same as prophylaxis of DVT following hip/knee replacement*
DABIGATRAN = Pradaxa
- *Reduction in STROKE risk & Systemic Embolism in Non-Vascular AF**
- *DOSING**
Reduction in STROKE risk & Systemic Embolism in Non-Vascular AF
CrCl > 30:
150mg BID
CrCl: 15 - 30
75mg BID
CrCl <15 or Dialysis
no dosing rec
CrCl 30 - 50 + P-gp Inhibitor
if Dronedarone or Ketoconazole –> 75mg BID
CrCl <30 + P-gp Inhibitor
AVOID co-admin
Apixaban
Eliquis
DOSING:
↓Risk of Stroke + PEinNonvalvular AFIB
5mg BID
2.5mg BID –> if 2 of the following:
> 80 y/o
Weight < 60kg
Scr > 1.5mg/dL
Apixaban
Eliquis
DRUG INTERACTIONS
P-gp + Strong CYP3A4 INDUCERS
P-gp + Strong CYP3A4 INDUCERS
RIFAMPIN / Carbamazepine / Phenytoin
BARBITURATES / St. Johns Wort
AVOID WITH APIXABAN
decrease apixaban exposure
same as DABIGATRAN
Which AC drug should you AVOID/CONTRAINDICATED
with
P-gp INDUCERS
Rifampin / Carbamazepine / Phenytoin
St. John’s Wort / Ritonavir / Avasimibe
DABIGATRAN
APIXABAN** + **EDOXABAN
+barbiturates
Edoxaban
Savaysa
Contraindications
P-gp INDUCERS
Rifampin / Carbamazepine / Phenytoin
- *CrCl > 95** for AFIB
- still 60mg qd for VTE/PE treatment*
CrCl < 15
Weight <60 kg
Edoxaban
Savaysa
DOSING:
Non-valvular AFib
- *CrCl 50-95**
- *60mg QD**
- *CrCL 15-50**
- 30mg QD**, no clinical data*
- CrCL > 95* or wt <60kg _or CrCL < 15_
- CONTRAINDICATED*
Apixaban
Eliquis
DOSING:
TREATMENT of DVT + PE
5mg BID
2.5mg BID –> if 2 of the following:
> 80 y/o
Weight < 60kg
Scr > 1.5mg/dL
Which AC drug(s) inhibit
IIa?
DABIGATRAN (Pradaxa)
DIRECT THROMBIN INHIBITOR
Indications for
DABIGATRAN = Pradaxa
Treatment of DVT & PE
150mg BID after 5-10 days of Parenteral AC
Prophylaxis of DVT & PE** **following HIP REPLACEMENT
110mg first day –> 220mg QD
Reduction in Stroke Risk & Systemic Embolism
150mg BID
Which AntiCoagulant can NOT be CRUSHED?
DABIGATRAN = Pradaxa
Capsule w/ small pellets, preserves gut absorption even when HIGH pH
Apixaban
Eliquis
DOSING:
Prophylaxis of DVTfollowing Hip/Knee replacement
- *2.5mg BID**
- same as reduction in risk for recurrent DVT & PE*
Which AC drug requires
HEPATIC DOSE ADJUSTMENT?
And What is recommended?
APIXABAN
Mild = Okay
Moderate = limited data
Severe = NOT RECOMMENDED
Dabigatran
has limited data in Hepatic Impairment + Obesity
Edoxaban
Savayasa
DVT/PE Treatment Dosing
no Indication for VTE prophylaxis
DVT/PE Treatment
TREAT FIRST WITH 5-10 DAYS of LMWH or UFH
CrCl >95 or 50-95
60mg qd
- *CrCl >15-50** or Weight < 60kg** or **With Pg-P INHIBITOR
- *30mg qd**
- *CrCl < 15_ or _w/ Pg-P Inducer**
- CONTRAINDICATED*
Which AC drugs are
DAILY DOSING?
Warfarin
EDOXABAN = SAVAYSA
Rivaroxaban
BID for 21 days –> then once Daily
Rivaroxaban
Xarelto
DOSING:
NonValvular AFIB
CrCl >50 mL/min:
20mg QD + evening meal
CrCl <50 mL/min:
15mg QD + evening meal
DABIGATRAN = Pradaxa
Prophylaxis of DVT & PE following
HIP REPLACEMENT SURGERY
DOSING
Prophylaxis of DVT & PE following
HIP REPLACEMENT SURGERY
CrCl >30:
110mg for first day –> 220mg QD
CrCl < 30 or Dialysis
dosing not provided
CrCl <50 + P-gp Inhibitor
AVOID co-admin
Apixaban
Eliquis
Metabolism
- *CYP3A4**
- not affected by food*
Prolongs:
PT/INR+aPTT
Which DOAC is a Prodrug?
DABIGATRAN = Pradaxa
After PO admin:
rapid absorption & CONVERSION by esterase-catalyzed hydrolysis in LIVER
2-3 Hour onset
Rivaroxaban = Xarelto
Metabolism / Drug Interactions
92-95% protein binding
metablolized by:
CYP3A4
Prolongs INR
Renally Dosed
Betrixaban
Bevyxxa
Indications
ONLY 1 INDICATION
- *HOSPITILIZED**
- *Acute medical illness who are AT RISK for VTE**
still a Factor Xa inhibtor –> ORAL instead of enoxaparin?
Rivaroxaban
Xarelto
DOSING:
Reduction in Risk of DVT +/- PE
in patients at risk for DVT/ PE
CrCl >50 mL/min:
20mg QD + evening meal
CrCl <50 mL/min:
15mg QD + evening meal
Dabigatran = Pradaxa
Metabolism / Elimination
RENALLY EXCRETED
moderate / severe renal impairment –> reduce dose
no CYP450 metabolism
LOW PROTEIN BINDING
can be removed by hemodialysis
Prolongs Clotting Time of:
PT / aPTT / ECT / TCT
Dabigatran = Pradaxa
ADR
- *DYSPEPSIA**
- *GI Side Effects**
Bleeding –> BEERS Criteria
(>75 yo)
Dispense in original bottle / blister package
Apixaban
Eliquis
DRUG INTERACTIONS
P-gp + Strong CYP4A4 Inhibitors
P-gp + Strong CYP4A4 Inhibitors
Ketoconazole / Itraconazole / Ritonavir
↓Dose by 50% if taking 5mg or 10mg BID
AVOID if taking 2.5mg BID
