27 - AntiCoag Special Populations Flashcards

1
Q

Contraceptives & AntiCoagulant Use

A

MOST Scenarios are FINE

Main issue:
AVOID CHC in those who are at HIGH RISK for RECURRANT DVT
(Combined hormonal contraceptives)
&
Do NOT get PREGNANT when on AC’s

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2
Q

2018 ASH Recommendations:

Treatment of VTE in PREGNANCY

A

Pregnant + Acute VTE:
Recommend LMWH** **BID Dosing for ALL 9 MONTHS
LMWH > UFH / VKA

Acute PE + Hemodynamic Instability:
Systemic Thrombolytic Therapy + AC Therapy

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3
Q

When would we use

UFH > LMWH

in PREGNANCY?
VTE

A

SEVERE RENAL DYSFUNCTION

Normally, LMWH is the drug of choice for
prevention of VTE in Pregnancy

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4
Q

When would we use:

FONDAPARINUX

over LMWH in PREGNANCY?

A

ALLERGIES to UFH/LMWH
or
HIT** or **H/o of HIT

Normally, LMWH is the drug of choice for
prevention of VTE in Pregnancy

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5
Q

Aspirin Use in Pregnancy?

A

ASPIRIN CROSSES THE PLACENTA

  • *First Trimester:
  • Unclear Safety*–>USE if indication is CLEAR**

2nd & 3rd Trimester
Low Dose Aspirin for women AT RISK FOR PREECLAMPSIA
safe for both baby * fetus

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6
Q

Warfarin use in Pregnancy

A

CONTRAINDICATED = Crosses Placenta
except:
MHV (Mechanical Heart VALVES)
& High risk for TE

Week 6-12 of Pregnancy:
Nasal Hypoplasia / Stripped epiphyes / Respiratory deficiency

2nd + 3rd Trimesters:
CNS toxicity / mental retardation / fetal death

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7
Q

Use of Anticoagulants

  • *POST PARTUM**
  • in patients recieving EPIDURAL CATHETERS*
A

BID Therapeutic LMWH
resumed:
24 hours after
NON-high bleeding risk surgery

or
48 - 72 hours after
HIGH BLEEDING RISK SURGERY

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8
Q

POSTPARTUM
Anticoagulant Therapy

A

VKA x 6 weeks with a target INR 2.0– 3.0,
with initial UFH
Or
LMWH overlap until the INR is >2.0
Or
prophylactic or intermediate-dose
LMWH for 6 weeks

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9
Q

What AC’s can be used during BREASTFEEDING?

A

LMWH** / **UFH

WARFARIN

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10
Q

What AC’s can NOT be used during BREASTFEEDING?

A

DOACS** / **DABIGATRAN

Fondaparinux

ASPIRIN
Reye’s syndrome

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11
Q

What is the
HAS-BLED Score

used for?

A

Estimates:
BLEEDING RISK** in **AFIB
useful in CKD

HTN - Abnormal RENAL/LIVER fxn - Stroke

Bleeding history - Labile INR - Elderly >65 - Drugs/alcohol

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12
Q

ESRD** & **BLEEDING RISK

A

SCr > 1.5mg/dl
associated with INCREASED RATES of MAJOR BLEEDING

HAS-BLED says ↑Rates of bleeding for:
Long Term Dialysis / Kidney Transplantation
or
SCr > 2.26 mg/dL

CKD ↑ likelyhood of ALL 3 VIRCHOWS components
Hypercoagulable state / Stasis / Vascular Injury

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13
Q

AFIB** & **CKD
Relationship

A
  • *Independent**
  • *INVERSE RELATIONSHIP**

GFR -> ↑AFib Prevalence

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14
Q

PK Differences among LMWH

More RENAL elimination
VS
More LIVER elimination

A

MOST RENAL
ENOXAPARIN
Has Renal Adjustment
VV
Dalteparin
VV
Tinzaparin
VV
UFH
MOST LIVER ELIMINATION

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15
Q

Which LMWH is RENALLY DOSED?

and WHAT is the dose?

A
  • *ENOXAPARIN**
  • *CrCL < 30:**
  • *30mg QD for Prophylaxis** (normal 40)
  • *1mg/kg QD for Treatment** (normal BID)

Dalteparin / Tinzaparin / Fondaparinux
caution / caution / contraindicated
for Cr CL<30

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16
Q

ACCP 2012 Guidelines:

Preferred AC for:
Renal Insufficiency & Therapeutic AC required

A

UFH > LMWH
UFH monitors aPTT

but:
if LMWH is still used –> monitor ANTI-Xa

17
Q

Which AC drugs are at risk for

THROMBOCYTOPENIA?

A

UFH** >&> **LMWH

18
Q

Which DOAC can be used in
ESRD / DIALYSIS?

A

APIXABAN
AF + Dialysis = 5mg BID
VVV
Reduce dose to:
2.5 mg BID if:
Age > 80 or Weight < 60 kg

Apixaban 5mg may be associated w/ lower risk vs warfarin
and reduce mortality / thromboembolic risk

19
Q

DOACs** & **OBESITY

A

DOACs should NOT be used in…

BMI > 40
or
Weight > 120kg

due to limited date

20
Q

Which AC drugs have WEIGHT CONSIDERATIONS?

Obesity

A

WARFARIN
fine, monitor INR @ any weight

HEPARIN
weight based dosing = TBW + Monitor aPTT

LMWH
use weight based dosing > fixed dosing
for both prophy & treatment for OBESE patients

  • *Fondaparinux**
  • *weight based dosing: >100kg**
  • *Weight limit for < 50kg**, avoid for prophylaxis
21
Q

Anticoagulation Weight Considerations

FONDAPARINUX

A

FONDA

> 100kg = special weight based dosing

  • *< 50kg**
  • weight LIMITS* & do NOT use for PROPHYLAXIS
  • increased risk for beeding*
22
Q

Anticoagulation Weight Considerations

LMWH

A

LMWH

Use WEIGHT BASED DOSING > Fixed dosing
for:
Obese Patients for BOTH Prophylaxis & treatment

Consider monitoring:
Anti - Xa esp if prolonged use or renal dysfxn

23
Q

Which DOAC should be AVOIDED in:
RENAL DEFICIENCY
?

A
  • *DABIGATRAN**
  • *Dialyzable + 80% Renal Excretion**

All other DOAC’s are also not recommended
EXCEPT for:
Apixaban –> special dosing

24
Q

AC & Cancer

Anticoagulant Recommendation

A

Currently:
LMWH > Warfarin or DOAC
but….
Some studies showing DOAC = First line for VTE in cancer patients
due to:
↓VTE OCCURANCE
but still has:
CRNMB (clinically relevant nonmajor bleeding) = GI/GU bleeds

25
Q

AC & Cancer

Which DOAC’s are approved for VTE + CANCER?
+ Trial Results

A

EDOXABAN** + **RIVORAXABAN
okay to use instead of LMWH
EXCEPT FOR:
HIGH RISK OF BLEEDING