Anti - Coagulants/Platelets & Thrombolytics Flashcards
What is the difference between anticoagulants and thombrolytics?
Anticoagulants - Prevent fibrin formation
Thrombolytics - Break down fibrin
Describe the coagulation cascade,
What is a normal aPTT?
What if they were on heparin?
How often do you test for aPTT if on heparin?
When do you test for aPTT?
20-40 seconds
1.5-2.5x the normal
Every 6 hours
Only for heparin IV not subq
What is the normal INR goal on warfarin and when does it change?
2-3
If patient has mechanical heart valve then it is 2.5-3.5 OTHER THAN aortic stenosis which is back to 2-3
What class of medications is NOT recommended for DVT/VTE/PE treatment?
What is preferred for patients with DVT and cancer?
Which DOAC’s require bridging? And for how long?
Thrombolytics
Apixaban > LMWH > Warfarin
Dabigatran and edoxaban must be bridged with UFH or LMWH for 5-10 days
What are the heparin dosing’s of treatment of DVT?
What about lovenox?
What is the difference between heparin PPX and TX?
Heparin continious - 5000-10000 bolus then 1000.hour
Heparin weight based -
Loading dose - 80 units/kg
Maintenance dose - 18u/kg/HOUR
Lovenox SX 1mg/kg SC Q12H OR 1.5mg/kg daily
Heparin PPX is subQ and TX is IV
How do you change the heparin TX dose accordingly to aPTT?
<35 s - 80u/kg bolus then 18u/kg/hour
35-45s - 40u/kg bolus then increase 2u/kg/hour
46-70 s- no change
71-90s - Decrease by 2u/kg/hour
> 90s - Hold infusion 1 hour then decrease by 3u/kg/hour
What is the process of starting warfarin with parenteral anticoags?
Start warfarin same day as UFH/LMWH and check INR in 3-5 days. Once INR is within goal for 2 consecutive days, you can stop UFH/LMWH.
We don’t often check levels for LMWH. But who would we check for and what is the lab?
Obese, underweight, renal and pregnant patients
Anti-xA levels 4 hours after SubQ
When/how long do you anticoagulate for distal and proximal DVT?
Distal (Below the knee) - if mild, don’t, but if severe then for 3 months.
Proximal or arm - 3 months if provoked and extended is unprovoked.
What is the heparin dosing for PPX?
What is the renal adjustment?
What are three ADE’s?
SubQ 5000-10000u Q8-12H
THERE IS NO RENAL ADJUSTMENTS
Bleeding, HIT, hyperK+
What two drugs may decrease the effect of heparin?
Ortiavancin and telavancin
What is HIT and when are you concerned?
What are other options for it?
Heparin induced thrombocytopenia that occurs 5-14 days after starting heparin and is due to anti-heparin antibodies that form.
Platelet count dropping by >50% from baseline and is often <100,000.
DTI - Argatroban and Bivalirudin
FXaI - Fondaparinux (SQ)
Fondaparinux
Brand
Dose
Renal dosing
ROA
Arixtra
DVT PPX - 2.5mg daily
DVT TX
<50kg - 5mg QD
50-100kg - 7.5mg D
>100kg - 10mg QD
Contraindicated in CrCl <30
SubQ
Enoxaparin dosing
DVT PPX hip/knee replacement
DVT PPX abdominal surgery
DVT TX
MI/UA/PCI
- 30mg Q12H or 40mg QD
If CrCl <30 - 30mg QD - 40mg QD
- 1mg/kg Q12H or 1.5mg/kg QD
If CrCL <30 - 1mg/kg QD - 30mg IV bolus with 1mg/kg SQ Q12H with aspirin
If >75 - 0.75mg/kg Q12H
What are the dosage form for lovenox?
What is an interesting administration counseling point?
What allergy should avoid lovenox?
Prefilled
30mg/0.3mL and 40mg/0.4mL
Graduate prefilled
60mg/0.6mL
80mg/0.8mL
100mg/1mL
120mg/0.8mL
150mg/mL
Multidose
300mg/3mL
You must inject while laying down.
Pork allergy
What are the options for LMWH overdose/?
Protamine
What are the 4 DTI’s, ROA, and brand?
Argatroban - IV
Bivalirudin (Angiomax) - IV
Desirudin (Iprivask) - SQ
Dabigatran (Pradaxa) - PO
Desirudin
Brand
ROA
Indication
Dose
ADE
Iprivask
SQ
DVT PPX after hip replacement surgery
15mg SQ Q12H
Allergic reactions
Dabigatran
Dosage forms
Administration instructions
Indication and dosing
What drug to avoid?
What is the process of moving from Pradaxa to warfarin?
What about for surgery?
What is the antidote?
75mg, 110mg, 150mg
Do NOT open capsules
- Nonvalvular Afib
CrCL >30 - 150mg BID
CrCl 15-30 - 75mg BID - Treatment
CrCl >30 - 150mg BID after 5-10 days of bridging - Reduction in risk of DVT/PE -
CrCl >30 - 150mg BID - PPX after hip replacement
CrCL >30 - 110mg day 1 then 220mg QD x 28-35 days
Rifampin because it’s a PGP inducer
If CrCl >50 - start warfarin 3 days before d/c pradaxa
If 31 -50 - start 2 days
If 15-30 - start 1 day
D/C pradaxa 1-2 days before surgery if CrCl >50 and 3-5 days if CrCl <50
Idarucizumab (Praxibind) - IV
Rivaroxaban
Brand
ROA
Dose (PPX, AFib, TX)
Renal dosing
Antidote
Xarelto
PO
DVT PPX - 10mg QD
Afib - 20mg QD w/FOOD
DVT TX - 15mg BID x 3 weeks then 20mg QD x 3 months
CrCl<30 - Don’t use
Andexanet alfa
Apixaban
Brand
ROA
Dose
Renal dosing
Eliquis
PO
Afib - 5mg BID
*** If 2/3 (Scr>1.5 , >80y.o , <60kg) do 2.5mg BID
DVT PPX/TX - 10mg BID x 7 days then 5mg BID
Edoxaban
Brand
ROA
Dose
Renal dosing
Savaysa
PO
DVT PPX/TX - 60mg QD
**IF <60kg OR CRCL 15-30 - 30mg QD
Afib - 60mg QD
Do not use if CrCl <15 or >95
Warfarin
Typical starting dose
Colors acronym
Two drugs that can decrease effectiveness
2 Drugs and herbs that can increase INR
2.5-5mg QD (elderly/HF/renal or liver disease ) or 10mg QD (healthy)
Please Let Greg Tan Bring Peaches to Your Wedding
1 - 2 -2.5 -3 -4 -5 -6 - 7.5 - 10
Rifampin and phenytoin
Bactrim, flagyl, garlic/ginger/ginkgo
Vitamin K Dosing for Warfarin
INR >10 but not bleeding - PO Vitamin K 2.5-5mg and hold warfarin
Serious bleeding regardless of INR -
Slow IV vitamin K 5-10mg WITH 4 factor PCC
INR 4.5-10 with high risk bleeding -
1-2.5mg PO vitamin K
What are your glycoprotein 11b/111a antagonists?
Abciximab (ReoPro)
Tirofiban (aggrastat)
Eptifibatide (Integrilin)
Tirofiban
Brand
Indications
Administration
Aggrastat
UA/non-STEMI/PCI
Continuous infusion b/c of super short half-life
Eptifibatide
Brand
Indication
Renal dosing
Integrilin
ACS/PCI
Dose adjust with CrCl <50
What are your ADP receptor antagonists?
P2Y12 inhibitors ‘
Thienopyridines
1. Cilostazol (Pletal)
2. Clopidogrel (Plavix)
3. Prasugrel (Effient)
4. Ticagrelor (Brilinta)
Non-Thienopyridine
5. Cangrelor (Kengreal)
Clopidogrel
MOA
Dose
PgX
Surgery
Irreversible inhibitor of P2Y12 ADP
300-600mg LD then 75mg QD MD
CYP2C19 convert prodrug into active drug - don’t combine with 2C19 inhibitors like PPI’s
D/C 5 days before surgery
Prasugrel
MOA
Dose
ADE
Surgery
Irreversible inhibtor
LD with 60mg then 10mg QD MD
Causes more bleeding than plavix
D/C 4 days before elective surgery and 7 days before CABG
Ticagrelor
MOA
Indication
Surgery
ADE
Drug interactions
Box warning
Reversible inhibition
ACS/ ischemic stroke
stop 5 days before surgery
SOB and increase uric acid
Can increase simvastatin and lovastatin levels
No more than 100mg of aspirin daily because it can reduce effectiveness of Brilinta
Cangrelor
ROA
Indication
Transition to oral
IV
Adjunt to PCI to decrease MI risk
Stop cangrelor THEN give plavix or effient.
Ticagrelor can be given at any time during cangrelor infusion.
What is Reye’s syndrome?
Occurs in children recovering from viral infection, flu, or chicken pox
Can causes liver and brain swelling.
Can be caused if giving aspirin to <12 y.o
Dipyridamole
Brand
MOA
Dose
Combinations
Persantine
Reversible inhibitor and vasodilator
75-100mg QID with water 1 hour before meals
Aggrenox = Aspirin + Er dipyridamole for stroke preventionVo
Vorapaxar
Brand
MOA
Indication
Dose
Half-life
Zonitivity
PAR-1 inhibitor
Secondary prevention of MI along with aspirin 81mg/plavix
2.08mg QD
Long half life (5-13 days)
Thrombolytic MOA
Directly activate plasminogen into plasmin so it can break down fibrin
Alteplase dosing
Reteplase dosing
Tenecteplase dosing
Only one approved for stroke - 0.9mg/kg (MAX 90mg)
Acute MI - 10U IV over 2 minutes with second dose after 30 minutes
Acute ischemic stroke - 0.25mg/kg bolus over 5 seconds (MAX 25mg)
