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Theraputics Winter > Anticoagulant √ > Flashcards

Anticoagulant √ Flashcards

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1
Q

What are the 2 genetic condition that produce hypercoagulable state

A

Leiden mutation
Gene 20210A mutation

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2
Q

what is secondary acquired thrombosis

A

HITTS

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3
Q

what are some hyper coagulable conditions

A
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4
Q

Risk factor for VTE event

A
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5
Q

Wells score DVT

A
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6
Q

wells score PE

A
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7
Q

3 DVT symptoms

A

unilateral leg swelling
Pain behind the knees when the foot is flexed
palpable cord in superficial

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8
Q

5 PE symptoms

A

Dyspnea
tachycardia
Tachypena
chest pain
chest tightness

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9
Q

DVT diagnosis

A

Elevated D dimer >240
wells score ≥2

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10
Q

PE diagnosis

A

V/Q mismatch
Elevated D dimer
Simplified wells score >4

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11
Q

VTE treatment Pathway

A
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12
Q

Name 9 Patients that are at risk of major bleed on a anticoagulant

A

The first few days and weeks of therapy
Age 65+
on NSAID, Aspirin, or GI bleeding
High-risk fall patients
Recent Trauma Patients
Heavy Alcholol use
Cancer
Renal failure
Cerebrovascular disease

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13
Q

In the Treatment pathway, what are the 2 criteria that allow use of Fibronlytics

A

DVT at risk for Gangrene and limb loss
Hemodynamically unstable PE (<90 SBP, blood loss, Shock, any heart abnormality)

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14
Q

patient is not in shock or <90 SBP when can we still think about using fibrinolytics

A
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15
Q

What are the 10 contraindications for Fibrinolytics

A

1.Previous intracranial hemorrhage at any time
2.Intracranial or intraspinal surgery within 2 months
3.Significant closed head or facial trauma within 3 months
4.Active internal bleeding (not including menses)
5.Ischemic stroke within 3 months (except ischemic stroke within 4.5 hours)
6.For streptokinase, prior streptokinase treatment within the previous 6 months
7.Known structural vascular lesion (e.g., arteriovenous malformation, AVM)
8.Suspected aortic dissection
9.Severe uncontrolled hypertension (unresponsive to emergency therapy)
10. Known malignant intracranial cancer

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16
Q

What needs to be administered before Fibrinolytics?

A

Heparin

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17
Q

Do we stop heparin when given with fibrinolytics?

A

In America common to stop but can continue if needed

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18
Q

Loading dose and maintenance dose of heparin?

A

LD - 80 units/kg bolus IV (DNE 10,000 units)
Main - 18 units/kg/hour (DNE 2,150 per hour)
USE ACTUAL BODY WEIGHT
ITS UNITS

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19
Q

Which Fibrinolytics can we use for DVT or PE

A

Alteplase - mainly seen
Streptokinase
Urokinase

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20
Q

How do we administer Alteplase

A

PE: 100mg IV infusion over 2 hours once
Cardiac arrest: 50mg IV Bolus once

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21
Q

What do we give to a patient who has a PE and has a cardiac arrest

A

50mg IV bolus once

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22
Q

How do we administer Streptokinase

A

250,000 IV units once
100,000 contiuos IV over 24 hrs

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23
Q

How do we adminster Urokinase

A

4,400 units/kg over 10mins
4,400 units/kg over 12 hours

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24
Q

VTE strats

A
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25
What meds can we give for acute phase treatment (day 5-10) of VTE
Heparin LWMH Fondaparinix Rivaroxaban or Apixaban
26
What are the 2 LWMH
enoxaparin (lovenox) Dalteparin (fragmin)
27
What is Fondaparinux
Anti Xa heparin Derivative
28
Apixaban dosing for VTE
10mg PO BID 7 days 5mg BID for 3 months 2.5 mg after 6 months
29
Rivaroxaban dosing for VTE
15 mg po BID for 21 days 20 mg QD for 3 months 10 mg QD after 6 months
30
Dabigatran Dosing for VTE
heparin 5-10 days 150 mg po BID
31
Edoxaban Dosing for VTE
Heparin for 5-10 days Edoxaban 60 mg daily for 6 months Dabigatran 150 mg BID for lifetime
32
Warfarin Dosing for VTE
heparin at least 5 days while taking warfarin QD until INR reaches ≥ 2 then send home with range 2 - 3 for at least 24hrs
33
Can heparin dissolve clots?
No only fibrinolytic can like alteplase
34
which heparin is NOT renal excreted
Unfractionated heparin
35
What labs do we order with Heparin
CBC aPPT PT/INR BUN Serum Creatine
36
what routine labs do we run with Heparin?
aPPT/ Anti-Xa, 6 hours after bolus, every 6 hours till 2 therapeutic then monitor daily if change in dose every 6 hours CBC daily if pretreatment <100,000 platelets every 72 if pretreatment >100,000
37
Goal aPPT and Anti Xa
aPPT 50-77 Anti Xa 0.3-0.7 IU/ml
38
What are the 3 major side effect of Heparin
Narrow therapeutic window Heparin-induced thrombocytopenia (HIT) Hemorrhage (minor to major) Hypersensitivity reactions (rare) – fever, chills, Hyperkalemia (rare) - only one teach saw Osteoporosis (rare) Reverse anticoagulation by stopping infusion +/- administration of protamine
39
SC Heparin dosing
5,000 units IV or 333 units/kg SC x 1 followed by 250 units/kg SQ BID or 110% of total daily IV requirements if switching from IV to SQ for discharge NOT VERY COMMON
40
What option do we have with LWMH
Enoxaparin (Lovenox) Dalteparin (Fragmin)
41
Which heparin has a lower HIT rate
LWMH
42
do we monitor aPPT or anti Xa in LWMH
Anti Xa
43
Normal dosing for Enoxaparin
1mg/kg BID or 1.5-2mg/kg daily
44
Normal dose for Dalteparin
1st Month 200IU/kg max 18,000 2- 6 months 150 IU/kg max 18,000 Both SQ and daily
45
4 patient populations that require special dosing for LWMH
1. obese 2. renal impairment Crcl <30 3. elderly 4. cancer
46
How do I recognize HIT
Platelet count drop of 50% (even if nadir > 150,000) from baseline Venous or arterial thrombosis Skin lesions at heparin injection sites Acute systemic (anaphylactoid) reactions that occur after a bolus of IV heparin
47
HIT vs HAT onset
HIT 4-14 days unless 3 had heparin 3 months ago ≤ 1day onset HAT <4 days faster onset
48
4 T test ranges and the percentage of HIT
≤ 3 low 4 - 5 intermediate 6 - 8 high
49
What do we do when a patient has HIT
DC heparin initiate anti-coag Fondaparinux, Bivalirudin, Argatroban transition to oral anti-coag to platelet recovery of ≥150^10 continue anti-coag 1 month or until ≥ 150^10 3 months if acute thrombosis 6 months if need anti-coag for something else
50
Why do we use Fondaparinux for HIT
when patients are stable and low risk of bleeding
51
When do we use Bivalirudin and Argatroban
ICU, dialysis, < 30 CrCl, bleeding risk, urgent procedure and life threatening thrombosis
52
Is Fondaparinux (Arixtra) a heparin?
NO
53
DVT/PE dosing for Fondaparinux
Weight < 50 kg: 5 mg SQ daily Weight 50-100 kg: 7.5 mg SQ daily Weight > 100 kg: 10 mg SQ daily CLcr < 30 mL/min: CONTRAINDICATED
54
can we use aPPT to monitor Arixtra?
no only Anti-Xa
55
Why cant Arixtra be use to bridge thrombin
bc it has no effect on thrombin inhibition
56
What is the indication for Bivalirudin?
Alternative to Heparin in HIT Alternative to heparin in CABG or Angioplasty
57
What is the indication for Argatroban
Alternative to Heparin in HIT
58
Bivalirudin and Argatroban aPPT range?
45-75 seconds
59
What is the benefit of Argatroban
hepatic elimination rather than renal
60
Why cant Argatroban be used to bridge warfarin
Causes PT/INR elevation
61
Angiomax dose
Bilvalirudin 0.15 mg/kg/hr
62
what type of anticoagulants are bivalirudin and Argatroban?
direct thrombin inhibitors
63
Argatroban dose
2 mcg/kg/min IV
64
Pradaxa renal dosing cut off
<30 CrCl do not use <50 CrCl w PgP inhibitors do not use (ketoconazole, quinidine, verapamil, erythromycin, cyclosporine, amiodarone, or dronedarone)
65
Xeralto renal dosing cut off
<15 CrCl do not use
66
Eliquis renal dosing cut off
NONE
67
Savaysa renal dosing cut off
CLcr > 50 mL/min and after 5-10 days of parenteral therapy: Weight > 60 kg: 60 mg PO daily For CLcr 15-50 mL/min or weight ≤ 60 kg or who use certain P-gp inhibitors1: 30 mg PO daily CLcr < 15 mL/min: do not use for the treatment of VTE
68
What is an patient education for Xeralto
take medication with an evening meal
69
What is an patient education for Pradaxa
use within 4 months and keep in original bottle
70
What is are patient educations for DOAC
Do not abruptly stop report any prolonged bleeding or unexpected bleeding other blood thinners will put you more at risk of a bleed out
71
CYP2C9 *2 and *3 require more or less warfarin
less bc it metabolizes slower
72
VKORC1 requires more or less warfarin
Less Hetero 25% Homo 50%
73
Starting dose of Warfarin
74
how much do we raise or lower warfarin
2.5 or 50% whichever is loss
75
what are the lowering factors for warfarin
Dose Lowering Factors * Weight < 45 kg * Malnourishment * Baseline INR > 1.3 * Albumin < 3 gm/dL * Liver disease * Catabolic conditions (recent surgery, hyperthyroidism, ADHF, pneumonia) * Taking azole antifungals, metronidazole, Septra, amiodaron
76
What are the raising factors for warfarin
Dose Raising Factors * Weight > 90 kg * Untreated hypothyroidism * Receiving enteral feeds * Taking rifampin, carbamazepine, dicloxacillin, phenobarbital, bosentan
77
The usual INR is 2-3 when do we raise it
mech or prostetic heart 2.5 - 3.5
78
Drugs that raise warfarin metabolism
Carbamazepine Phenytoin Phenobarbital Rifampin / Rifabutin St. John’s wort
79
Drugs that decrease warfarin metabolism
Amiodarone Cimetidine Ciprofloxacin Erythromycin Fluconazole Fluvastatin Ginseng Itraconazole Ketoconazole Metronidazole Trimethoprim / Sulfamethoxazole
80
What are the 4 toxicities with Warfarin
Bleeding Birth defect skin necrosis Purple toe syndrome
81
What are 10 patient educations for Warfarin
M 1. Minor bleedin is common 2. only 1 alcoholic drink 3. Warfarin decreases the activity of vitamin K = longer time it takes a clot to form 4. Never skip a dose or take a double dose 5. Serious but rare major bleeding (head, stool urine or eyes) 6. check for bleeding M 7. fall or head hit, seek medical attention 8. a lot of DDI talk to your doctor M 9. consistent intake of vitamin K
82
How to bridge heparin and warfarin?
start both on day 1 till day 5 after check if INR is in range 2-3 for 2 days then stop heparin and send home
83
Warfarin/DOAC duration
usually 3 months unless need to be given for life
84
When would I give warfarin/doac for life
low bleed risk for unprovoked or pt with cancer
85
in a patient with cancer what anticoagulant should i give
DOAC or LWMH warfarin not favored
86
when would i use a IVC filter
cant use anticoagulants active bleed
87
What neutralizes LWMH and dosing
Protamine Sulfate 1 mg : 100 units over 1-3 mins calculate half life to solve going bavk 5 Half lives DNE 50 mg
88
Can you reverse the effects of Enoxaparin
1 mg protamine: 1 mg enoxaparin (if enox. given < 8 hours ago) – 0.5 mg protamine: 1 mg enoxaparin (if enox. given > 8 hours ago)
89
Daily requirement of vita K
70 mcg/day
90
What are routes and administration and what is the preferred for vitamin K
PO but takes 24hrs for the max SQ is erratic IV can cause anaphylactic but fast onset (reserved for last resort)
91
Reversal of warfarin guidelines
92
when would I give Kccnetra over vitamin K
when they have a life-threatening bleed
93
Kccentra (4 factor prothrombin complex concentrate) dose
Rapid acting
94
what is the reversal agent for Dabigatran
Idarucizumab (PraxbindTM) DOSE:2.5g/50mLIVbolusx2(totaldose=5g)
95
how to reverse apixaban or rivaroxaban
Andexanet alfa

Theraputics Winter (16 decks)

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