27 - AntiCoag Special Populations

Question 1

Contraceptives & AntiCoagulant Use

Answer 1

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

Question 2

2018 ASH Recommendations:

Treatment of VTE in PREGNANCY

Answer 2

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

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

Question 3

When would we use

UFH > LMWH

in PREGNANCY?
VTE

Answer 3

SEVERE RENAL DYSFUNCTION

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

Question 4

When would we use:

FONDAPARINUX

over LMWH in PREGNANCY?

Answer 4

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

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

Question 5

Aspirin Use in Pregnancy?

Answer 5

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

Question 6

Warfarin use in Pregnancy

Answer 6

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

Question 7

Use of Anticoagulants

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

Answer 7

BID Therapeutic LMWH
resumed:
24 hours after
NON-high bleeding risk surgery
or
48 - 72 hours after
HIGH BLEEDING RISK SURGERY

Question 8

POSTPARTUM
Anticoagulant Therapy

Answer 8

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

Question 9

What AC’s can be used during BREASTFEEDING?

Answer 9

LMWH** / **UFH

WARFARIN

Question 10

What AC’s can NOT be used during BREASTFEEDING?

Answer 10

DOACS** / **DABIGATRAN

Fondaparinux

ASPIRIN
↑Reye’s syndrome

Question 11

What is the
HAS-BLED Score
used for?

Answer 11

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

HTN - Abnormal RENAL/LIVER fxn - Stroke

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

Question 12

ESRD** & **BLEEDING RISK

Answer 12

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

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

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

Question 13

AFIB** & **CKD
Relationship

Answer 13

• *Independent**
• *INVERSE RELATIONSHIP**

↓GFR -> ↑AFib Prevalence

Question 14

PK Differences among LMWH

More RENAL elimination
VS
More LIVER elimination

Answer 14

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

Question 15

Which LMWH is RENALLY DOSED?

and WHAT is the dose?

Answer 15

• *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

Question 16

ACCP 2012 Guidelines:

Preferred AC for:
Renal Insufficiency & Therapeutic AC required

Answer 16

UFH > LMWH
UFH monitors aPTT

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

Question 17

Which AC drugs are at risk for

THROMBOCYTOPENIA?

Answer 17

UFH** >&> **LMWH

Question 18

Which DOAC can be used in
ESRD / DIALYSIS?

Answer 18

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

Question 19

DOACs** & **OBESITY

Answer 19

DOACs should NOT be used in…

BMI > 40
or
Weight > 120kg

due to limited date

Question 20

Which AC drugs have WEIGHT CONSIDERATIONS?

Obesity

Answer 20

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

Question 21

Anticoagulation Weight Considerations

FONDAPARINUX

Answer 21

FONDA

> 100kg = special weight based dosing

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

Question 22

Anticoagulation Weight Considerations

LMWH

Answer 22

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

Question 23

Which DOAC should be AVOIDED in:
RENAL DEFICIENCY?

Answer 23

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

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

Question 24

AC & Cancer

Anticoagulant Recommendation

Answer 24

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

Question 25

AC & Cancer

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

Answer 25

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