27 - AntiCoag Special Populations Flashcards
Contraceptives & AntiCoagulant Use
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
2018 ASH Recommendations:
Treatment of VTE in PREGNANCY
Pregnant + Acute VTE:
Recommend LMWH** **BID Dosing for ALL 9 MONTHS
LMWH > UFH / VKA
Acute PE + Hemodynamic Instability:
Systemic Thrombolytic Therapy + AC Therapy
When would we use
UFH > LMWH
in PREGNANCY?
VTE
SEVERE RENAL DYSFUNCTION
Normally, LMWH is the drug of choice for
prevention of VTE in Pregnancy
When would we use:
FONDAPARINUX
over LMWH in PREGNANCY?
ALLERGIES to UFH/LMWH
or
HIT** or **H/o of HIT
Normally, LMWH is the drug of choice for
prevention of VTE in Pregnancy
Aspirin Use in Pregnancy?
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
Warfarin use in Pregnancy
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
Use of Anticoagulants
- *POST PARTUM**
- in patients recieving EPIDURAL CATHETERS*
BID Therapeutic LMWH
resumed:
24 hours after
NON-high bleeding risk surgery
or
48 - 72 hours after
HIGH BLEEDING RISK SURGERY
POSTPARTUM
Anticoagulant Therapy
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
What AC’s can be used during BREASTFEEDING?
LMWH** / **UFH
WARFARIN
What AC’s can NOT be used during BREASTFEEDING?
DOACS** / **DABIGATRAN
Fondaparinux
ASPIRIN
↑Reye’s syndrome
What is the
HAS-BLED Score
used for?
Estimates:
BLEEDING RISK** in **AFIB
useful in CKD
HTN - Abnormal RENAL/LIVER fxn - Stroke
Bleeding history - Labile INR - Elderly >65 - Drugs/alcohol
ESRD** & **BLEEDING RISK
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
AFIB** & **CKD
Relationship
- *Independent**
- *INVERSE RELATIONSHIP**
↓GFR -> ↑AFib Prevalence
PK Differences among LMWH
More RENAL elimination
VS
More LIVER elimination
MOST RENAL
ENOXAPARIN
Has Renal Adjustment
VV
Dalteparin
VV
Tinzaparin
VV
UFH
MOST LIVER ELIMINATION
Which LMWH is RENALLY DOSED?
and WHAT is the dose?
- *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
ACCP 2012 Guidelines:
Preferred AC for:
Renal Insufficiency & Therapeutic AC required
UFH > LMWH
UFH monitors aPTT
but:
if LMWH is still used –> monitor ANTI-Xa
Which AC drugs are at risk for
THROMBOCYTOPENIA?
UFH** >&> **LMWH
Which DOAC can be used in
ESRD / DIALYSIS?
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
DOACs** & **OBESITY
DOACs should NOT be used in…
BMI > 40
or
Weight > 120kg
due to limited date
Which AC drugs have WEIGHT CONSIDERATIONS?
Obesity
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
Anticoagulation Weight Considerations
FONDAPARINUX
FONDA
> 100kg = special weight based dosing
- *< 50kg**
- weight LIMITS* & do NOT use for PROPHYLAXIS
- increased risk for beeding*
Anticoagulation Weight Considerations
LMWH
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
Which DOAC should be AVOIDED in:
RENAL DEFICIENCY?
- *DABIGATRAN**
- *Dialyzable + 80% Renal Excretion**
All other DOAC’s are also not recommended
EXCEPT for:
Apixaban –> special dosing
AC & Cancer
Anticoagulant Recommendation
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
AC & Cancer
Which DOAC’s are approved for VTE + CANCER?
+ Trial Results
EDOXABAN** + **RIVORAXABAN
okay to use instead of LMWH
EXCEPT FOR:
HIGH RISK OF BLEEDING
