Anti Coag Special Populations Flashcards
CKD Dose Adjust of Renally Elim PARENTERAL Anti coags : Dalteparin
-If CrCL < 30 mL/min What do u adjust the dose to?
avoid
Enoxaparin :
-If CrCL 20-30 mL/min?
-If CrCL < 20 mL/min or on dialysis?
-Hospitalized pt’s can use (Enox)?
1 mg/kg SQ daily
UFH is preferred !
-Hospitalized pt’s can use 0.7 mg/kg SQ daily + trough anti-Xa levels
Bivalirudin :
-If CrCL 30-60 mL/min
-If CrCL 10-29 mL/min or CVVHD?
-If IHD?
These are ____ doses, adjust rate per ??
0.08 mg/kg/hr
0.05 mg/kg/hr
0.04 mg/kg/hr
starting, protocol and aPTT
Fondaparinux :
CrCl<30 mL/min
-What can u use to help guide therapy in CKD stage 3?
-What about ckd stage 4 or 5 ?
AVOID IN VTE
use antiXa levels
AVOID in CKD stages 4 and 5
Whats ur goal anti-Xa trough when using Enoxaparin in renally adjusted pt’s?
< 0.4 IU/mL
CKD Dose adjustments of DOACS When Treating VTE : DABIGATRAN
For CrCL < 30 mL/min?
For CrCL < 50 mL/min with concomitant use of PGP inhibitors,(Ketoconazole, quinidine, verapamil, erythro, cyclosporine, amio, dronedarone) ?
DONT USE
avoid coadmin
A. RIVAROXABAN when TREATING VTE :
CrCL < 15 mL/min?
B. APIXABAN ADJUSTMENT?
DONT USE
NO RENAL DOSE ADJ. 10 mg po bid for 7 days then 5 mg PO BID afterwards
C. EDOXABAN
For CrCL 15-50 mL/min or weight <= 60 kg or who use certain PGP inhibitors?
For CrCL < 15 mL/min?
30 mg PO DAILY
dont use for tx of VTE
What are some high risk patient groups that may require LMWH monitoring with Anti-Xa levels? (4)
Obesity
renal impairment with CrCL < 30
Elderly + Children
Cancer pt’s
OBESITY BMI > 40 kg/m^2 : For each state the prophylaxis dosing and the therapeutic dosing adjustments
- UFH
- LMWH
- Fondaparinux
- DTI’s
- Warfarin
- Consider higher doses like 7500 units SQ TID or 10k units sq BID if weight > 120 kg
-Can follow anti Xa levels
No adjust needed
- 0.5 mg/kg SQ daily or 30% incr from standard dose + anti Xa monitoring
for VTE : 0.75 mg/kg SQ BID (use actual body weight) + anti Xa monitoring
- no recs
-fixed dose of 10 mg SQ daily for weight > 100 kg for VTE. Can use anti Xa to monitor - n/a
use actual body weight. titrate to effect based on aPTT
- n/a
may require higher initial dose at start but titrate towards INR endpoint
Obesity and DOACs :
Which drugs are appropriate options regardless of high BMI and weight for tx of VTE?
Suggest not to use the following for VTE tx in obese pt’s?
apixaban or rivaroxaban
Dabigatran, edoxaban, Betrixaban
Indications for using Anti-thrombotics In pregnancy? (Pre existing Disease)
-Acute VTE
* Chronic VTE
* Atrial fibrillation
* Valvular and structural
heart disease
* Ischemic stroke
* Acute coronary syndromes
* Peripheral artery occlusive
disease
Indications for using Anti-thrombotics In pregnancy? (Pre existing risk factors)
Hypercoagulable conditions such as AT deficiency or antiphospholipid syndrome
AntiCoag Recc in Pregnancy :
Which 2 agents can u use, and which 2 should u avoid?
LMWH : preferred. doesnt cross placenta, not transferred through breast milk
UFH : yes as alternative to LMWH. Preferred in pt’s with severe renal issues, doesnt cross placenta. Long term use –> Osteoporosis
Vitamin K antags (Avoid during preg if u can because it’s a teratogen and MAY Cross placenta)
DOACs (avoid during preg). Potential risk for fetal bleeding
LMWH in Pregnancy :
-What kind of monitoring to consider?
-In preg women with severe renal dysfunction?
-What kind of preparations to use?
For epidural catheter placement to minimize risk of spinal hematoma :
-How long do u have to wait between last therapeutic LMWH injection?
-How long must u wait between last PROPHYLACTIC LMWH injection?
When should pregnant women consider switching to UFH?
-Anti Xa
-UFH
-Preservative free (pre filled syringes)
- > = 24 hrs
- > = 12 hrs
36-37 weeks gestation
Development of cancer is associated with?
Tumor cells produce their own ??
What can also activate blood clotting?
Activation of blood coagulation
procoagulant factors
Anti-tumor drugs (chemotherapy)
Cancer Associated Thrombosis :
- Which drug class can u use for initial tx (10 days) and maintenance tx with CrCL > 30?
- What about DOACS in cancer pt’s not at high risk of GI or GU bleeding ?
- If LMWHs or DOACS are CI, what can u use?
- How long must u use LMWHs or DOACS to treat cancer associated thrombosis?
- LMWHs
- Apixaban or Rivaroxaban for initial tx (10 days) OR EDOXABAN (after 5 days of parenteral AC) and also can use these agents as maintenance tx
- UFH
- minimum of 6 months
PRIMARY PROPHYLAXIS of Asx Carriers of Inherited Thrombophilias :
A. This is not necessary unless there’s additional risk factors present such as?
B. If someone’s on hormonal therapy and may have inherited thrombophilia, what should be considered?
-What about recc’s regarding anticoag prophylaxis?
C. Pregnancy associated with Inherited thrombophilia –> recurrent fetal loss
In the antepartum period, if theyre AT3 deficient, what should u use as prophylaxis?
In postpartum period and AT3, protein c + s deficiency, whats prophylaxis?
A. using hormonal therapy and if they’re pregnant
B. Consider alternative method of contraception or avoid
- No reccs
C.
-UFH or LMWH prophylaxis.
-Prophylaxis with SQ UFH or LMWH or warfarin (target INR 2-3) for 6 weeks
For pt’s with Inherited Thrombophilia, minimum period of tx is at least how many months?
Which pt’s should u consider long term anticoag for?
For patients with 2 or more spontaneous episodes of VTE how long is therapy?
at least 3-6 months
-pt’s with protein C,S, deficiency with family history .
-For AT3 deficiency or antiphospholipid antibodies
indefinite therapy
Antiphospholipid Syndrome
-What kind of disorder?
-Associated with both?
-Clinical presentation includes? (4)
-Autoimmune disorder of hypercoagulability
-Arterial and venous thrombosis
-Thrombosis, recurrent miscarriage, thrombocytopenia, prolonged baseline aPTT
Lupus Anticoagulant and Interference w/monitoring parameters :
1) Pt’s with lupus anticoag have elevated ___ and prolongation of ____
-typically not associated with?
HEPARIN : what’s not a reliable predictor of therapeutic efficacy and what should u use in its place?
WARFARIN : Utilize chromogenic assay for factor X and use in which pt’s?
- baseline aPTTs , PT (falsely elevated INR)
-INCR risk of bleeding
aPTT, anti-Xa levels
pt’s with abnormal baseline INR
Timing of ANtiCOAG Interruption:
- Vitamin K antag (warfarin)
-When should you discontinue?
-Proceed with surgery when INR is? - DOACS
-High bleed risk procedure vs low bleed risk
-for individuals taking dabigatran with CrCL 30-50? - UFH
-Discontinue when?
-Preferred in which setting? - LMWH
-discontinue when?
-avoid in ?
-For BID dosing?
-For once daily dosing?
- discontinue 5 days prior to elective surgery +/- bridging with LMWH or heparin
<1.5 - discontinue doac two days before surgery day. Resume on second day after surgery .
-discontinue one day before surgery. continue day after surgery
- omit an additional dose before procedure
- Discontinue 4 hrs prior to procedure. Preferred in hospital due to quick onset and offset and reversability.
- Discontinue 24 hrs prior to procedure
-renal dysfunction
- omit evening dose prior to procedure
-give 1/2 dose on morning before day of surgery
Bridging Anticoag
-What does this involve?
-Which pt’s fit into the criteria to bridge?
Administration of short acting anticoag such as LMWH, during interruption of longer acting agent such as warfarin
Pt’s on vit k antag, procedure has low/mod/high risk of bleeding AND they have high thromboembolic risk
VTE prophylaxis Chart in hospitalized pt’s
See Chart
Reasons to NOT USE pharma VTE prophylaxis : RIsk factors for bleeding ?
1.Active ____
2.Bleeding how soon prior to admission?
3.Platelet count of?
4.Age?
5.___failure with INR of ?
6.Severe __?
gastroduodenal ulcer
3 months prior to admit
< 50 x 10^9/L
> = 85
Hepatic failure, >1.5
Renal dysfunction
