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Cardio Renal > Anticoagulants > Flashcards

Anticoagulants Flashcards

1
Q

Heparin MOA

A

potentiates anti thrombin

decreases pro thrombin –> thrombin

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2
Q

Heparin Route

A

SQ or IV

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3
Q

Heparin Renal Adjustments

A

None

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4
Q

Heparin Body Weight considerations

A

higher body weights may require higher dosing

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5
Q

Heparin Drug Interactions

A

Additive drugs can cause bleeding

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6
Q

Heparin Monitoring

A

anti Xa levels or aPTT

hemoglobin, hematocrit, platelets

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7
Q

Heparin Goal

A

anti Xa level 0.3-0.7 units/ml

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8
Q

LMWH aka…

A

Enoxaparin

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9
Q

LMWH MOA

A

potentiates antithrombin

inactivates factor Xa

(decreases pro thrombin –> thrombin)

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10
Q

LMWH Route

A

SQ or IV (rarely)

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11
Q

Heparin Half Life

A

1-2 hours

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12
Q

LMWH Half Life

A

12 hours

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13
Q

LMWH Renal Adjustments

A

CrCl <30 ml/min

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14
Q

LMWH Body Weight Considerations

A

BMI ≥ 40 kg/m2

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15
Q

LMWH Drug Interactions

A

Avoid additive increased bleeding risk

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16
Q

LMWH Monitoring

A

hemoglobin, hematocrit, platelets

serum creatinine

Anti Xa monitoring in obese, renal dysfunction, or pregnant patients

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17
Q

What class of medication is warfarin?

A

Vitamin K Inhibition

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18
Q

Warfarin MOA

A

Vitamin K Inhibition leading to a reduction in the hepatic synthesis of factors

II, VII, IX, X

and protein C/S by blocking carboxylation

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19
Q

Why does warfarin take effect at steady state?

A

Warfarin inhibits coagulation but also inhibits natural anti coagulation

At SS inhibiting coagulation is greater

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20
Q

Warfarin Route

A

20-60 hours

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21
Q

Warfarin Renal Adjustments

A

none

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22
Q

Warfarin Body Weight Considerations

A

higher body weights may require higher doses

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23
Q

Warfarin Common DDI

A 
Amiodarone
Macrolides
-azoles
Sulfa ABX
Rifampin
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24
Q

Warfarin CYP

A

2C9 major

3A4 minor

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25
Q

Warfarin Monitoring

A

INR 2-3

hemoglobin, hematocrit, platelets

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26
Q

Warfarin Limitations (5)

A
  1. Frequent INR monitoring
  2. Bridging requirements
  3. Peri-procedural anticoagulation
  4. Drug-drug interactions
  5. Drug food interactions
27
Q

Initial warfarin dose for patient starting on warfarin

A

5 mg daily for 3 days

28
Q

Initial warfarin dose for patient starting on warfarin (more sensitive)

A

2.5 mg daily for 3 days

29
Q

What makes a patient more sensitive to warfarin?

A

frail, elderly, undernourished
liver disease, kidney disease, HF
acute illness
on medication that decreases warfarin metabolism

30
Q

When do you check the INR on patient starting warfarin?

A

Day 4

31
Q

Goal of INR after 4 days after initiation

A

1.5 - 1.9

Continue starting dosing

32
Q

Patient starting on warfarin
On day 4 INR is < 1.5
What dose do you give them?

A

7.5 to 10 mg daily for 2-3 days

33
Q

Patient starting on warfarin
On day 4 INR is 2-3
What dose do you give them?

A

2.5 mg daily for 2-3 days

34
Q

Patient starting on warfarin
On day 4 INR is 3.1 - 4
What dose do you give them?

A

1.25 mg daily for 2-3 days

35
Q

Patient starting on warfarin
On day 4 INR is > 4
What dose do you give them?

A

Hold until INR < 3

36
Q

Sensitive Patient starting on warfarin
On day 4 INR is < 1.5
What dose do you give them?

A

5 - 7.5 mg daily for 2 - 3 days

37
Q

Sensitive Patient starting on warfarin
On day 4 INR is 1.5 - 1.9
What dose do you give them?

A

Continue starting dose

2.5 mg daily for 2-3 days

38
Q

Patient starting on warfarin
On day 4 INR is 1.5 - 1.9
What dose do you give them?

A

Continue starting dose

5 mg daily for 2-3 days

39
Q

Sensitive Patient starting on warfarin
On day 4 INR is 2 - 3
What dose do you give them?

A

1.25 mg daily for 2 - 3 days

40
Q

Sensitive Patient starting on warfarin
On day 4 INR is 3.1 - 4
What dose do you give them?

A

0.5 mg daily for 2 - 3 days

41
Q

Sensitive Patient starting on warfarin
On day 4 INR is >4
What dose do you give them?

A

Hold until INR < 3

42
Q

Patient already on warfarin

INR <1.5

A

Increase weekly maintenance dose by 10-20%

Consider one time 1.5-2 times the daily dose

43
Q

Patient already on warfarin

INR 1.5 - 1.7

A

Increase weekly maintenance dose by 5-15%

Consider one time 1.5-2 times the daily dose

44
Q

Patient already on warfarin

INR 1.8 - 1.9

A

No adjust if last 2 INRs in range

If need:
Increase weekly maintenance dose by 5-10%

Consider one time 1.5-2 times the daily dose

45
Q

Patient on warfarin
Taking ABX temporarily
What dosing do you do?

A

On time supplemental 1.5-2 times daily dose

Resume maintenance dose

46
Q

Patient already on warfarin

INR 3.1 - 3.2

A

No adjust if last 2 INRs in range

If need:
Decrease weekly maintenance dose by 5-10%

47
Q

Patient already on warfarin

INR 3.3 - 3.4

A

Decrease weekly maintenance dose by 5-10%

48
Q

Patient already on warfarin

INR 3.5 - 3.9

A

Consider holding 1 dose

Decrease weekly maintenance dose by 5-10%

49
Q

Patient already on warfarin

INR ≥4 but ≤10 and no bleeding

A

Hold until INR below 3
Decrease weekly maintenance dose by 5-20%
If patient considered to be a bleeding risk consider oral K

50
Q

Patient already on warfarin

INR >10 and no bleeding

A

Hold until INR below 3
Give vitamin K orally
Decrease weekly maintenance dose by 5-20%

51
Q

Factor Xa Inhibitors

A 
Rivaroxaban
Apixaban
Edoxaban
Betrixaban
Fonndaparinux
52
Q

Apixaban brand name

A

Eliquis

53
Q

Apixaban route

A

oral

54
Q

Apixaban A fib dose

A

5mg BID

55
Q

Apixaban VTE dose

A

10 mg BID x 1 wek

then 5 mg BID

56
Q

Apixaban half life

A

12 hours

57
Q

Apixaban renal adjustment

A

A fib Only
2.5mg BID if 2/3 are met:

SCr>1.5
Weight<60
Age>80

58
Q

Apixaban body weight considerations

A

Okay in those >120 kg or BMI ≥ 40

59
Q

Apixaban drug interactions

A

Major CYP3A4 substrate

60
Q

Apixaban monitoring

A

hemoglobin, hematocrit, platelets, serum creatinine

61
Q

Apixaban Pearls

A

Best DOAC in patients with poor renal function

62
Q

DOACs

A 
Apixaban 
Rivaroxaban
Edoxaban
Betrixaban
Dabigatran
63
Q

Patient already on warfarin
INR 3.5
Taking drug that temporarily dec. warfarin
What do you do?

A

One time held dose

Consider resumption of prior maintenance dose

Cardio Renal (1 decks)

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