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Therapeutics II > Anti-Coagulation Pre-Lecture > Flashcards

Anti-Coagulation Pre-Lecture Flashcards

1
Q

DVT Risk factors

A
  • obesity
  • > 40
  • family history of DVT
  • Immobilization > 10 days
  • heart failure
  • malignancy
  • MI
  • orthopedic injury
  • oral contraceptive/estrogen use
  • paralysis
  • postoperative state
  • pregnancy
  • prior DVT
  • varicose veins
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2
Q

UFH Key points

A
  • rapid
  • parenteral
  • goal aPTT = 1.5 - 2.5 x control (46 - 70 seconds)
  • Dosing (IV bolus = 80 U/kg, IV infusion = 18U/Kg/hr)
  • AE= bleeding, thrombocytopenia
  • rapid, variable
  • commonly a continuous infusion
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3
Q

HIT management

A
  • stop heparin
  • dont start warfarin until platelets >150,000
  • give alternate LMWH (levirubin, bivalirubin, argatroban, fondaparinux)
  • dont give platelet infusion
  • evaluate for thrombosis
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4
Q

Benefits of LMWH

A
  • good bioavailability = reduced protein bioavailability
  • good predictability
  • smaller molecule = good subQ absorption
  • long t1/2 = once or twice daily dosing
  • less effects on platelets = reduced thrombosis
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5
Q

Enoxaparin Brand

A

Levonox

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6
Q

Enoxaparin (Levonox) Prophylactic Dose Surgery

A

30 mg subQ q12h (surgery)

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7
Q

Enoxaparin (Levonox) Prophylactic Dose Medical

A

40 mg subQ daily (medical)

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8
Q

Enoxaparin (Levonox) Treatment Doses

A
  • 1.0 mg/kg q12h

- 1.5 mg/kg daily

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9
Q

Enoxaparin (Levonox) Key Point

A

Can be used with renal dysfunction (< 30ml/min)

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10
Q

Enoxaparin (Levonox) Renal Dysfunction Doses

A
  • 30 mg subQ DAILY (prophylactic)

- 1.0 mg/kg subQ DAILY (treatment)

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11
Q

Dalteparin (Fragmin) Key Points

A
  • Less common

- Treatment dose common for VTE cancer patients

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12
Q

Dalteparin (Fragmin) prophylactic dose

A

2500 - 5000 U subQ daily

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13
Q

Dalteparin (Fragmin) treatment dose

A

200 U subQ x 30 days QD, 150 U subQ daily (cancer treatment)

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14
Q

Monitoring anti Xa levels for LMWH

A

-consider for children, pregnant, severe kidney dysfunction, obese

  • tx:
  • **BID dosing 0.6 - 1.0 U/ml obtained 4 hours post dose
  • **QD dosing 0.1 - 0.3 U/ml obtained as a trough (checked prior to second dose)
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15
Q

Is monitoring anti Xa levels of LMWH recommended?

A

NOOOOOOO

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16
Q

Fondaparinux Labeled Uses

A
  • TKA
  • THA
  • Hip replacement
  • Abdominal surgery
  • TREATMENT OF DVT OR PE (OFTEN 1ST MED A PT CAN USE)
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17
Q

Fondaparinux prophylactic dose

A

2.5 mg subQ once daily (hip, knee or abdominal surgery)

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18
Q

Fondaparinux treatment dose

A
  • < 50 kg = 5mg subQ QD
  • 50 - 100 kg = 7.5mg subQ QD
  • > 100 kg = 10mg subQ QD
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19
Q

If pt has renal dysfunction < 30ml/min, can a pt use fondaparinux?

A

NOOOOOOOO

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20
Q

Fondaparinux can NOT be used prophylactically in patients with

A

low body weight < 50 kg. Can be used to treat pts < 50 kg

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21
Q

Can Fondaparinux be used to treat HIT

A

YESSSS

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22
Q

Routine monitoring of fondaparinux levels?

A

NOOOOO, but can choose to monitor anti-10a levels similar to LMWH

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23
Q

Fondaparinux safe for pregnancy

A

YES. Category B

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24
Q

IV direct thrombin inhibitors should be associated with

A

USE IN HIT

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25
Q

IV direct thrombin inhibitors

A
  • argatroban
  • bivalirubin (angiomax)
  • levirubin
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26
Q

Bivalirubin Brand

A

Angiomax

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27
Q

Argatroban KEY points

A
  • if pt has liver dysfunction, adjust dose:
  • **normal dose = 2 mcg/kg/min
  • **hepatic dysfunction dose = 0.5 mcg/kg/min
  • Causes a false elevation of INR
  • **overlap with warfarin until INR of 4 (most meds overlap until INR of 2)

-this medicine can cause hepatic dysfunction

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28
Q

For lepirubin, reduce dose

A

if CrCl is < 60 ml/min

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29
Q

LIST ALL NOACS/DOACS

A

-direct thrombin inhibitor = dabigatran (Pradaxa)

  • Factor Xa inhibitors:
  • **rivaroxaban (xarelto)
  • **apixaban (eliquis)
  • **edoxaban (savaysa)
  • **betrixaban (bevyxxa)
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30
Q

KEY THING TO REMEMBER ABOUT NOACS/DOACS

A

WHAT ARE THEY F-ING INDICATED FOR

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31
Q

Postoperative Prophylaxis

A

prevention of a postoperative DVT to PE in pts undergoing knee or hip surgery

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32
Q

Non valvular atrial fibrillation

A
  • THIS PIECE OF INFORMATION MUST BE GIVEN TO YOU

- general prevention of stroke and systemic embolism in pts with non-valvular atrial fibrillation

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33
Q

Indefinite anticoagulation (secondary prevention of recurrent DVT and/or PE)

A
  • reduction in the risk of a recurrent DVT and/or PE following initial 6 months of treatment
  • continuing an anti-coag after a pt has been on one for months
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34
Q

VTE prophylaxis

A

-prophylaxis of VTE in adults hospitalized for an acute medical illness who are at risk for thromboembolic complications due to immobility and other VTE risk factors

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35
Q

DABIGATRAN INDICATIONS

A
  • POST OPERATIVE PROPHYLAXIS (Hip)
  • NON-VALVULAR ATRIAL FIBRILLATION
  • DVT/PE TX
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36
Q

RIVAROXABAN INDICATIONS

A

EVERYTHING

  • POST OPERATIVE PROPHYLAXIS (Hip)
  • NON-VALVULAR ATRIAL FIBRILLATION
  • DVT/PE TX
  • SECONDARY PREVENTION OF RECURRENT DVT/PE
  • VTE PROPHYLAXIS
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37
Q

APIXABAN INDICATIONS

A
  • POST OPERATIVE PROPHYLAXIS (Hip)
  • NON-VALVULAR ATRIAL FIBRILLATION
  • DVT/PE TX
  • SECONDARY PREVENTION OF RECURRENT DVT/PE
38
Q

EDOXABAN INDICATIONS

A
  • NON-VALVULAR ATRIAL FIBRILLATION

- DVT/PE TX

39
Q

BETRIXABAN INDICATIONS

A

-VTE PROPHYLAXIS

40
Q

Rivaroxaban also approved for

A

reduction of risk of major CV events in pts with CAD or PAD

41
Q

Betrixaban other risk factors

A
  • great than or equal to 75 yoa
  • 60 - 74 yoa with D-dimers >/= 2 ULN
  • 40 - 59 yoa with D-dimers >/= 2 ULN and a history of VTE or cancer
42
Q

Warfarin Brands

A
  • coumadin

- jantoven

43
Q

Warfarin color is

A

CONSISTENT

44
Q

Warfarin challenges

A
  • drug drug interactions
  • narrow therapeutic window
  • drug and diet interactions
  • intersubject variablity
  • difficult to standardize labs
  • Good PK/PD understanding by both pt/provider
45
Q

Warfarin inhibits the synthesis of vitamin k dependent clotting factors

A
  • 2, 7, 9, 10

- Protein C + S

46
Q

Warfarin specifically inhibits the

A

enzyme responsible for cyclic conversion of vitamin K (vitamin K reductase)

47
Q

Warfarin anti-coag effect in

A

24 hours

48
Q

Warfarin peak effect

A

72 - 96 hours

49
Q

Warfarin duration of action from a single dose

A

2 - 5 days

50
Q

Warfarin S enantiomer hepatically metabolized by

A

2C9, 2C19, 2C18

51
Q

Warfarin R enantiomer hepatically metabolized by

A

1A2 and 3A4

52
Q

Factor t1/2 considerations

A
  • Factor II (prothrombin) = 60 -100 h
  • Factor 7 = 4 - 6 h
  • Factor 9 = 20 - 30 h
  • Factor 10 = 24 - 40 h
53
Q

VKORC1

A

reductase enzyme that forms the vitamin K which is converted to clotting factors

54
Q

Who should be tested for warfarin

A

ALL THREE THINGS NEED TO BE MET:

  • Insulin naiive
  • Will get results back before 6th dose
  • Pt is at a high risk of bleeding (for example on meds that increase bleeding risk)
55
Q

HIGHER THE INR

A

HIGHER THE BLEEDING RISK

56
Q

Drugs that increase INR

A
  • amiodarone
  • fluconazole
  • acute alcohol
  • metronidazole
  • fluconazole
  • ciprofloxacin
  • bactrim
  • liver disease
  • erythromycin
57
Q

Drugs that decrease INR

A
  • chronic use of alcohol
  • rifampin
  • cholestyramine
  • carbamazepine
58
Q

Aspirin and other NSAIDs impact on INR

A

-these meds increase bleeding HOWEVER do not increase INR

59
Q

How does vitamin K impact warfarin

A

it reverses warfarin activity

60
Q

Warfarin and chronic alcohol and liver damage

A

increase in INR

61
Q

Most common antiplatelets

A
  • COX 1 inhibitor = aspirin

- PDE III inhibitor = dipyridamole

62
Q

Consider dipyridamole use in VTE with

A

concomitant use of warfarin with prosthetic valves

63
Q

Consider ASA in VTE with

A

CHA2DS2 score 1

64
Q

Bleeding management steps

A
  • discontinue medication
  • apply manual compression
  • maintain bp
  • surgical or radiological intervention
  • blood products +/- PCC +/- targeted antidotes
65
Q

Consider activated charcoal for bleeding

A

if there is = 2 hours of bleeding

66
Q

When pt is bleeding and on hemodialysis

A

use dabigatran only

67
Q

UFH, LMWH reversal agent

A

protamine sulfate

68
Q

Dabigatran reversal agent

A

idarucizumab (Praxbind)

69
Q

Factor Xa inhibitors

A

Andexanet alfa

70
Q

UFH infusion antidote directions

A

1 mg protamine/100 units UFH given over the past 3 hours

71
Q

LMWH antidote directions

A
  • within 8 hours of last LMWH
  • **1 mg per 100 anti-factor Xa units
  • **1 mg per 1 mg enoxaparin
  • > 8 hours
  • **0.5 mg per 100 anti-factor Xa units
  • **0.5 mg per 1 mg enoxaparin
72
Q

Adverse reactions of protamine sulfate antidote

A
  • hypotension
  • bradycardia
  • How to fix: slow the infusion (over 1 - 3 minutes), max can give is 50 mg over 10 minutes
73
Q

Idarucizumab (Praxbind) MOA

A

direct binder to dabigatran (higher affinity than dabigatran to thrombin)

74
Q

Idarucizumab Dose

A
  • 5g IV

- 2 separate 2.5 g doses no more than 15 minutes apart

75
Q

Idarucizumab monitoring

A

Baseline aPTT, repeat in 2 hours, every 12 hours until normal

76
Q

Andexanet alfa (andexxa) binds and sequesters

A

rivaroxiban and apixaban

77
Q

Warfarin Bleeding Management dependent on (2 things)

A

INR and presence/absence of bleeding

78
Q

Warfarin bleeding management: Vitamin K

A
  • Oral (PREFERRED): 5 mg tablets

- Parenteral: Don’t exceed 1 mg/min (otherwise will trigger anaphylaxis)

79
Q

Warfarin bleeding management: Fresh Frozen Plasma (FFP)

A

10 - 15 ml/kg

80
Q

Warfarin bleeding management: Prothrombin Complex Concentrate (PCC)

A

30 IU/kg (check INR before, 30 - 60 minutes after)

81
Q

Warfarin bleeding management: IF INR 4.5 - 10 AND NO EVIDENCE OF BLEEDING

A

Avoid vitamin K

82
Q

Warfarin bleeding management: IF INR > 10 AND NO EVIDENCE OF BLEEDING

A

PO vitamin K

83
Q

Warfarin bleeding management: Major bleeding while on warfarin

A

PCC preferred over FFP. May add vitamin K 5 - 10 mg as well

84
Q

Warfarin reversal: Rapid (complete, w/in 10 - 15 min)

A

Prothrombin complex concentrate + IV vitamin K

85
Q

Warfarin reversal: Fast (partial)

A

Fresh frozen plasma

86
Q

Warfarin reversal: Prompt (w/in 4-6 hours)

A

IV vitamin K

87
Q

Warfarin reversal: Slow (w/in 24 hours)

A

PO vitamin K

88
Q

Warfarin reversal: Very slow (3 - 5 days)

A

Omit warfarin (no vitamin K)

89
Q

VTE prophylaxis options

A
  • unfractionated heparin
  • LMWH
  • Factor Xa inhibitors
  • Vitamin K antagonist (warfarin)
90
Q

Moderate VTE risk

A
  • general surgery pts = UFH, LMWH, Factor Xa inhibitor = continue prophylaxis up to 28 days after hospital discharge
  • acutely ill medical patients = UFH, LMWH, fondaparinux, rivaroxaban, *BETRIXABAN = For UFH, LMWH, fondaparinux = No specific recommendations for post discharge

~Specific total tx regiments:

  • **rivaroxaban = 31 - 39 days
  • **betrixaban = 35 - 42 days
91
Q

High VTE risk

A
  • orthopedic surgery (TKA or THA)
  • LMWH, fondaparinux, rivaroxaban, apixaban, dabigatran (hip), UFH, or vitamin k antagonist - FDA approved
  • continue >/= 10 - 14 days post opp (consider up to 35 days)

Therapeutics II (12 decks)

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