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Theraputics Winter > Anticoagulant > Flashcards

Anticoagulant Flashcards

1
Q

What are the 2 genetic condition that produce hypercoagulable state

A

Leiden mutation
Gene 20210A mutation

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2
Q
A
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3
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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4
Q

5 PE symptoms

A

Dyspnea
tachycardia
Tachypena
chest pain
chest tightness

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5
Q

DVT diagnosis

A

Elevated D dimer >240
wells score ≥2

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6
Q

PE diagnosis

A

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

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7
Q

VTE treatment Pathway

A
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8
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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9
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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10
Q

What are the 10 contraindications for Fibrinolytics

A

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

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11
Q

What needs to be administered before Fibrinolytics?

A

Heparin

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12
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

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13
Q

Which Fibrinolytics can we use for DVT or PE

A

Alteplase
Streptokinase
Urokinase

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14
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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15
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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16
Q

How do we administer Streptokinase

A

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

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17
Q

How do we adminster Urokinase

A

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

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18
Q

Apixaban dosing for VTE

A

10mg PO BID 7 days
5mg BID for 6 months
2.5 mg BID for lifetime

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19
Q

Rivaroxaban dosing for VTE

A

15 mg po BID for 21 days
20 mg QD for 6 months
10 mg QD for lifetime

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20
Q

Dabigatran Dosing for VTE

A

heparin 5-10 days
150 mg po BID for lifetime

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21
Q

Edoxaban Dosing for VTE

A

Heparin for 5-10 days
Edoxaban 60 mg daily for 6 months
Dabigatran 150 mg BID for lifetime

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22
Q

Warfarin Dosing for VTE

A

heparin at least 5 days
while taking warfarin QD until INR reaches ≥ 2
then send home with range 2 - 3 for at least 24hrs

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23
Q

Can heparin dissolve clots?

A

No only fibrinolytic can like alteplase

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24
Q

which heparin is NOT renal excreted

A

Unfractionated heparin

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25
Q

What labs do we order with Heparin

A

CBC
aPPT
PT/INR
BUN
Serum Creatine

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26
Q

what routine labs do we run with Heparin?

A

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

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27
Q

Goal aPPT and Anti Xa

A

aPPT 50-77
Anti Xa 0.3-0.7 IU/ml

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28
Q

How do we adjust heparin based on aPPT and Anti Xa

A
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29
Q

What is the scaling to increase infusion for heparin

A

.08 - increase by 1 unit/kg/hr
.1 - bolus 40 unit/kg/ then increase infusion 2 units/kg/hr
<.1 bolus 80 units/kg then increase infusion 4 units/kg/hr

aPPT
increments of 6 starting from 49

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30
Q

What is the scaling to decrease infusion for heparin

A

.14 Decrease but 1 unit/kg/hr
.13 hold for 30 mins then decrease 2 units/kg/hr
.1 hold for 1 hr then decrease 3 units/kg/hr
>1.1 hold 1 hr then decrease 4 units/kg/hr NOTIFY provider

aPPT
7
10
8
14
>200 HOLD AND CONTACT PROVIDER

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31
Q

What are some side effect of Heparin

A

Narrow therapeutic window
Heparin-induced thrombocytopenia (HIT)
Hemorrhage (minor to major)
Hypersensitivity reactions (rare) – fever, chills,
Hyperkalemia (rare)
Osteoporosis (rare)
Reverse anticoagulation by stopping infusion +/- administration of protamine

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32
Q

SC Heparin dosing

A

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

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33
Q

What option do we have with LWMH

A

Enoxaparin (Lovenox)
Dalteparin (Fragmin)

34
Q

Which heparin has a lower HIT rate

A

LWMH

35
Q

do we monitor aPPT or anti Xa in LWMH

A

Anti Xa

36
Q

How do I recognize HIT

A

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

37
Q

HIT vs HAT onset

A

HIT 4-14 days unless 3 had heparin 3 months ago ≤ 1day onset

HAT <4 days faster onset

38
Q

4 T test and the percentage of HIT

A

≤ 3 low
4 - 5 intermediate
6 - 8 high

39
Q

What do we do when a patient has HIT

A

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

40
Q

When do we use Fondaparinux for reversal

A

when patients are stable and low risk of bleeding

41
Q

When do we use Bivalirudin and Argatroban

A

ICU, dialysis, < 30 CrCl, bleeding risk, urgent procedure and life threatening thrombosis

42
Q

Is Fondaparinux (Arixtra) a heparin?

A

NO

43
Q

DVT/PE dosing for Fondaparinux

A

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

44
Q

can we use aPPT to monitor Arixtra?

A

no only Anti-Xa

45
Q

Why cant Arixtra be use to bridge thrombin

A

bc it has no effect on thrombin inhibition

46
Q

Bivalirudin and Argatroban aPPT range?

A

45-75

47
Q

What is the benefit of Argatroban

A

hepatic elimination rather than renal

48
Q

Why cant Argatroban be used to bridge warfarin

A

Causes PT/INR elevation

49
Q

Angiomax dose

A

0.15 mg/kg/hr

50
Q

Argatroban dose

A

2 mcg/kg/min IV

51
Q

what are the DOAC we can use for DVT/PE

A

Dabigatran
Apixaban
Rivaroxaban
Edoxaban

52
Q

Pradaxa renal dosing cut off

A

<30 CrCl do not use
<50 CrCl w PgP inhibitors do not use (ketoconazole, quinidine, verapamil, erythromycin, cyclosporine, amiodarone, or dronedarone)

53
Q

Xeralto renal dosing cut off

A

<15 CrCl do not use

54
Q

Eliquis renal dosing cut off

A

NONE

55
Q

Savaysa renal dosing cut off

A

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

56
Q

What is an patient education for Xeralto

A

take medication with an evening meal

57
Q

What is an patient education for Pradaxa

A

use within 4 months and keep in original bottle

58
Q

What is are patient educations for DOAC

A

Do not abruptly stop
report any prolonged bleeding or unexpected bleeding
other blood thinners will put you more at risk of a bleed out

59
Q

CYP2C9 *2 and *3 require more or less warfarin

A

less bc it metabolizes slower

60
Q

VKORC1 requires more or less warfarin

A

Less
Hetero 25%
Homo 50%

61
Q

Starting dose of Warfarin

A
62
Q

how much do we raise or lower warfarin

A

2.5 or 50% whichever is loss

63
Q

what are the lowering factors for warfarin

A

Dose Lowering Factors
* Weight < 45 kg
* Baseline INR > 1.3
* Malnourishment
* Albumin < 3 gm/dL
* Liver disease
* Catabolic conditions (recent surgery, hyperthyroidism, ADHF, pneumonia)
* Taking azole antifungals, metronidazole, Septra, amiodaron

64
Q

What are the raising factors for warfarin

A

Dose Raising Factors
* Weight > 90 kg
* Untreated hypothyroidism
* Receiving enteral feeds
* Taking rifampin, carbamazepine, dicloxacillin, phenobarbital, bosentan

65
Q

The usual INR is 2-3 when do we raise it

A

mech or prostetic heart 2.5 - 3.5

66
Q

Drugs that raise increase warfarin metabolism

A

Carbamazepine
Phenytoin
Phenobarbital
Rifampin / Rifabutin
St. John’s wort

67
Q

Drugs that raise decrease warfarin metabolism

A

Amiodarone
Cimetidine
Ciprofloxacin
Erythromycin
Fluconazole
Fluvastatin
Ginseng
Itraconazole
Ketoconazole
Metronidazole
Trimethoprim / Sulfamethoxazole

68
Q

Day 1 - 4 of warfarin what do you do

A
69
Q

What are the 4 toxicities with Warfarin

A

Bleeding
Birth defect
skin necrosis
Purple toe syndrome

70
Q

What are 10 patient educations for Warfarin

A
  1. An anticoagulant that helps reduce the formation of clots in
    your blood
  2. Blood clots are formed through a series of chemical reactions in your body, vitamin K is necessary for those reactions
  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. The International Normalized Ratio (INR) is the blood test used to determine how thin your blood is
  6. check for bleeding
  7. fall or head hit, seek medical attention
  8. a lot of DDI talk to your doctor
  9. consistent intake of vitamin K
  10. only 1 alcoholic drink
71
Q

Warfarin/DOAC duration

A
72
Q

Are IVC filters good?

A

not really limited data and you can not use ANTICOAGULANTS

73
Q

What neutralizes LWMH and dosing

A

Protamine Sulfate
1 mg : 100 units over 1-3 mins
DNE 50 mg

74
Q

Can you reverse the effects of Enoxaparin

A

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)

75
Q

Daily requirement of vita K

A

70 mcg/day

76
Q

What are routes and administration and what is the preferred

A

PO but takes 24hrs for the max
SQ is erratic
IV can cause anaphylactic but fast onset (reserved for last resort)

77
Q

Reversal of warfarin guidelines

A
78
Q

Kccentra (4 factor prothrombin complex concentrate) dose

A

Rapid acting

79
Q

what is the reversal agent for Dabigatran

A

Idarucizumab (PraxbindTM)
DOSE:2.5g/50mLIVbolusx2(totaldose=5g)

80
Q

how to reverse apixaban or rivaroxaban

A
81
Q
A

Theraputics Winter (12 decks)

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