Anticoagulant

Question 1

Heparin Dosing

Answer 1

PPX: 5,000 units SC BID

VTE TX: 80 u/kg bolus then 18 u/kg/hr inf

STEMI: 60/12

All use TBW

Question 2

Enox/Lovenox Dosing

Answer 2

PPX: 30 mg BID or 40 mg QD SC
(<30 CrCl then 30 mg QD)

VTE: 1 mg/kg BID or 1.5 mg/kg QD (IP)
(<30 CrCl then 1 mg/kg QD)

Question 3

Anti-Xa Monitoring

Answer 3

For LMWH

Helpful in:
-Pregnancy
-Renal insufficiency
-Obesity/frail
-Elderly

Question 4

Eliquis Dosing

Answer 4

DVT/PE: 10 mg BID x7d then 5 mg BID (after 6mo, 2.5 mg BID)

A-fib: 5 mg BID
(2.5 mg BID if <60kg, Scr 1.5+, 80+ yr)

PPX hip/knee: 2.5 mg BID (given 12-24 hrs after surgery)

Question 5

Xarelto Dosing

Answer 5

Doses 15+ mg WITH FOOD

DVT/PE: 15 mg BID x21d then 20 mg QD with food
(<15 CrCl avoid)

A-fib PPX:
CrCl >50: 20 mg QD
CrCl 15-50: 15 mg QD
CrCl <15: 15 mg QD per mft (limite data)

Question 6

Conversion Between Warfarin and DOACs

Answer 6

Warfarin to DOAC
-Riva when INR <3
-Edox when INR <2.5
-Apix when INR <2
-Dabi when INR <2

DOAC to Warfarin
-Stop DOAC, start parenteral AC and warfarin at next scheduled dose
-For dabi: start warfarin 1-3 days before stopping dabi

Question 7

Dabigatran/Pradaxa Dosing

Answer 7

A-fib: 150 mg BID
-CrCl 15-30: 75 mg BID
-CrCl < 15: avoid

DVT/PE: 150 mg BID after 5-10 days of parenteral AC
-CrCl < 30: avoid

Question 8

Warfarin Counseling

Answer 8

1. Indication
2. INR?
3. AEs (minor/major) - fall/hit head: ER
4. DDIs with meds (abx/SJW/NSAID)
5. Food consistency

Question 9

CHADSVASC Score

Answer 9

C - CHF
H - HTN
A - Age 75+ (2)
D - Diabetes
S - Stroke/TIA (2)
V - Vascular Disease (PAD/MI)
A - Age 65-74 (1)
S - Female Sex

Question 10

Surgery

Answer 10

-Stop warfarin 5 days before major surgery
-Stop LMWH 24 hours before major surgery
-Stop heparin 4 hours before major surgery