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Anticoags, antiplatelet and DOACs Flashcards

1
Q

Unfractionated heparin class

A

Anticoagulants

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2
Q

Fractionated LMW Heparin (Lovenox) class

A

Anticoagulants

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3
Q

Warfarin (Coumadin) class

A

Anticoagulants

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4
Q

Clopidogrel (Plavix) drug class

A

Antiplatelet Drugs

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5
Q

ASA class

A

Antiplatelet Drugs

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6
Q

Abixaban (Eliquis) drug class

A

DOACs (direct oral anti-coagulants)

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7
Q

Dabigatran (Pradaxa) class

A

DOACs (direct oral anti-coagulants)

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8
Q

Rivaroxaban (Xarelto) class

A

DOACs (direct oral anti-coagulants)

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9
Q

Heparin Sodium (UFH) route

A

SQ , IV

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10
Q

UFH:

  1. time to onset
  2. half life
A

Time to onset : (IV) immediate; SQ (20 min);

1⁄2 life: 1.5hrs

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11
Q

UFH indications

A
  1. Thromboembolism prophylaxis/treatment
  2. Acute coronary syndromes
  3. Patency of catheters via continuous infusion or line flushing
  4. DIC
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12
Q

UFH MOA

A

Antithrombin II catalyst which binds and inactivates factors IIa and Xa

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13
Q

UFH AE

A
  • Bleeding
  • hypersensitivity
  • *transient vs (HIT) thrombocytopenia
  • chest pain
  • thrombosis
  • vasospasm
  • chills
  • headache
  • peripheral neuropathy
  • GI effects (N/V/constipation)
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14
Q

UFH CI

A
  • history of HIT
  • IM injection
  • active bleeding
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15
Q

UFH pearls

A

Give SQ dosing within 2hrs of operation for VTE prophylaxis VTE prophylaxis dosing every 8-12hrs, SQ In a patient on continuous IV heparin gtt (ie for inpatient clot tx) monitor levels and adjust to therapeutic dosing via hourly aPTT For patients on heparin gtts, can turn off AM before surgery (easy on, easy off due to short 1⁄2 life) then restart immediately after surgery aPTT monitoring is NOT indicated for VTE prophylaxis dosing (8-12 hr SQ dosing)

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16
Q

Enoxaparin (Lovenox) route

A

SQ

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17
Q

Enoxaparin (Lovenox) onset and peark

A

3-5hrs, duration: 12hrs

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18
Q

Enoxaparin (Lovenox) indications

A

Acute coronary syndrome (unstable angina, NSTEMI/STEMI), DVT prophylaxis/treatment, bridge therapy (off-label use for mechanical valves, interruption of Vit K antagonist therapy), VTE during pregnancy (off-label)

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19
Q

Enoxaparin (Lovenox) MOA

A

acts as anticoagulant by optimizing inhibition of clotting factors. Has small effect on aPTT and strongly inhibits factor Xa over factor IIa

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20
Q

Enoxaparin (Lovenox) AE

A

Bleeding, anemia. *US Boxed Warning: Epidural and spinal hematomas w/ neuroaxial anesthesia and LP. Peripheral edema, confusion, nausea, fever, HIT

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21
Q

Enoxaparin (Lovenox) CI

A

Hypersensitivity to enoxaparin, heparin, hx of HIT, pork products, or benzyl alcohol, active major bleeding, and thrombocytopenia w/ in vitro testing for antiplatelet antibodies Precaution in elderly

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22
Q

Enoxaparin (Lovenox) pearls

A

Generally, once a day dosing for VTE prophylaxis. Some ortho surgeries, twice daily for VTE prophylaxis When using to treat a DVT, dosing = 1mg/Kg twice daily, SQ Serum levels are not monitored with aPTT More expensive than unfractionated heparin Must increase dosing for BMI > 40mg/m2

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23
Q

Warfarin (Coumadin) route

A

PO

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24
Q

Warfarin (Coumadin) indications

A

Prophylaxis and treatment of VTE and embolic complications related to Afib (valvular and non-valvular), mechanic prosthetic heart valves, post MI

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25
Q

Warfarin (Coumadin) MOA

A

Vitamin K antagonist

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26
Q

Warfarin (Coumadin) AE

A

US Boxed Warning: *Potentially fatal bleeding

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27
Q

Warfarin (Coumadin) CI

A

Pregnancy (teratogenic), any active bleed, hypersensitivity, recent surgery of the eye or CNS, blood dyscrasias, *patients prone to non-compliance, falls Precaution in renal disease

28
Q

Warfarin (Coumadin) pearls

A

Once daily dosing D/C 5 days before surgery, consider bridging based on VTE risk, resume 12-24 hrs after surgery The goal of anticoagulant therapy is to prevent further extension of an already formed thrombus and to prevent secondary thromboembolic complications Antibiotics effect efficacy, must monitor INR more closely Only consider in a post 1st trimester, pregnant patient with a mechanical heart valve (high risk of stroke) Avoid foods high in Vit K (green leafy vegetables, green tea, cooking oils) PT/INR monitoring: outpatient usu. weekly, if dose changes usu. Q 2-3 days

29
Q

Warfarin onset and peak

A

24-72 hrs, Peak: 5-7 days, expect INR to raise q36-72 hrs

30
Q

Clopidogrel (Plavix) route

31
Q

Clopidogrel (Plavix) indications

A

acute coronary syndrome, recent MI/stroke, unstable angina, established peripheral arterial disease, CAD, cardioembolic stroke, carotid artery stenting (off-label)

32
Q

Clopidogrel (Plavix) MOA

A

inhibits platelet aggregation by inhibiting adenosine diphosphate (ADP)- induced pathway

33
Q

Clopidogrel (Plavix) AE

A

*GI bleed, minor to major hemorrhage, itching, rash, URIs, chest pain, headache, arthralgia, pain, bruising, diarrhea

34
Q

Clopidogrel (Plavix) CI

A

*US Box warnings: dependent on CYP P450 (CYP2C19) for activation; poor CYP2C19 metabolizers should use another platelet inhibitor Hypersensitivity, active pathologic bleeding Precaution in kidney disease

35
Q

Clopidogrel (Plavix) pearls

A

D/C 5 days before surgery Severe side effects include severe neutropenia, TTP, acute liver failure, aplastic anemia, hepatitis, and agranulocytosis Off label uses for ASA allergic patients Avoid with grapefruit juice, decreases efficacy of drug

36
Q

Apixaban (Eliquis) route

37
Q

Apixaban (Eliquis) indications

A

Stroke prevention in A-Fib: CHA2D2S-VASc ≥ 2 or consider at 1, if other than female sex Active DVT/PE or risk of DVT/PE from recent surgery

38
Q

Apixaban (Eliquis) MOA

A

electively blocks active site of factor Xa, inhibiting blood coagulation Metabolized in the kidney and liver

39
Q

Apixaban (Eliquis) AE

A

*US Boxed Warnings: Increased thrombotic event risk when premature D/C, epidural/spinal hematoma risk and LP. Bleeding, anemia, nausea, thrombocytopenia, hypersensitivity rxn or syncope

40
Q

Apixaban (Eliquis) CI

A

Allergy, active major bleeding, Child-Pugh Class C, acute PE with hemodynamic instability, requiring thrombolysis or pulmonary embolectomy Caution with age > 80, wt < 60 kg, Cr >1.5, spinal puncture, epidural or prosthetic heart valve

41
Q

Apixaban (Eliquis) pearls

A

Best option of class for renal concerns Twice daily dosing Ok to d/c 2-3 days before general surgery, D/C 5-7 days prior to spinal procedure Bridge Tx not indicated

42
Q

Rivaroxaban (Xarelto) route

43
Q

Rivaroxaban (Xarelto) indications

A

Stroke prevention in A-Fib: CHA2D2S-VASc ≥ 2 or consider at 1, if other than female sex Active DVT/PE or risk of DVT/PE from recent surgery

44
Q

Rivaroxaban (Xarelto) MOA

A

Selectively blocks active site of factor Xa, inhibiting blood coagulation

45
Q

Rivaroxaban (Xarelto) AE

A

*US Boxed warnings: Increased thrombotic event risk when premature D/C, epidural/spinal hematoma risk w/ neuroaxial anesthesia and LP. Bleeding, back pain, pruritus, ALT elevation, agranulocytosis, thrombocytopenia, Steven-Johnson syndrome, hepatitis

46
Q

Rivaroxaban (Xarelto) CI

A

Allergy, active major bleeding, Child-Pugh Class B or C, CrCl <30, Acute PE with hemodynamic instability, requiring thrombolysis or pulmonary embolectomy or pregnancy. Caution with CrCl 30-50 DVT prophylaxis, CrCl 15-50 for thromboembolism/stroke prophylaxis, elderly, Cr >1.5, spinal puncture, epidural or prosthetic heart valve

47
Q

Rivaroxaban (Xarelto) pearls

A

Once daily dosing available Ok to d/c 2-3 days before general surgery, D/C 5-7 days prior to spinal procedure Bridge Tx not indicated

48
Q

Dabigatran (Pradaxa) route

49
Q

Dabigatran (Pradaxa) indications

A

Stroke prevention in A-Fib: CHA2D2S-VASc ≥ 2 or consider at 1 , if other than female sex Active DVT/PE or risk of DVT/PE from recent surgery *Not for initial presentation presentation of DVT/PE

50
Q

Dabigatran (Pradaxa) MOA

A

Directly, reversibly inhibits thrombin Product metabolized in the kidney

51
Q

Dabigatran (Pradaxa) AE

A

*US Boxed warnings: Increased thrombotic event risk with premature D/C, epidural/spinal hematoma risk with neuroaxial anesthesia and LP. Bleeding, *dyspepsia, gastritis, GI bleeding, thrombocytopenia, hypersensitivity rxn or anaphylaxis

52
Q

Dabigatran (Pradaxa) CI

A

Allergy, active major bleeding, or mechanical heart valve. Caution with age > 75, spinal puncture, epidural or prosthetic heart valve

53
Q

Dabigatran (Pradaxa) pearls

A

*Only DOAc with reversal agent, Idarucizumab (Praxbind) Twice a day dosing D/C 5-7 days prior to spinal procedure, 2-3 days before general surgery Bridge Tx not indicated

54
Q

DOAC Advantages

A

Lower all cause mortality No lab monitoring Less diet and drug interactions No bridge therapy pre-op

55
Q

DOAC Disadvantages

A

Some are 2x/day dosing Expensive! Avoid in: Prosthetic valve, pregnancy, BMI > 40kg/m2 Antidote only for Pradaxa

56
Q

Heparin & warfarin Advantages

A

Cheap Heparin products ok for pregnancy Available antidotes Preferred anticoagulant for renal impaired Missed doses, less harmful Warfarin: once daily

57
Q

Heparin & warfarin Disadvantages

A

Increased bleeding complications Warfarin: teratogenic, CI in pregnancy

58
Q

Reversal Agents for UFH and Fractionated LMW Heparin (Lovenox)

A

protamine sulfate

59
Q

Reversal Agents for Warfarin (Coumadin)

A

vitamin K, FFP

60
Q

Anticoagulants that have reversal agents

A

UFH, Fractionated LMW Heparin (Lovenox) and Warfarin (Coumadin)

61
Q

DOACs (direct oral anti-coagulants) with reversal agents

A

Dabigatran (Pradaxa)

62
Q

Dabigatran (Pradaxa) reversal agent

63
Q

What can you consider as a reversal agent if a pt was given Clopidogrel (Plavix)

A

platelet transfusion

64
Q

What can you consider as a reversal agent if a pt was given ASA

A

platelet transfusion

65
Q

DOAC Drugs

A
  1. apixaban (Eliquis®)
  2. betrixaban (BevyxXa®)
  3. dabigatran (Pradaxa®)
  4. edoxaban (Savaysa®)
  5. rivaroxaban (Xarelto®)

CTS Drugs (4 decks)

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