Anticoagulants

Question 1

NOAC OD:

Answer 1

…limited data.

R
- Usual

R
- Any dose potentially signif
- Standard coag levels don’t correlate well with risk… need more specific assays

S
ANTICIPATE:
- Bleeding is only risk

-MANAGEMENT
- AC: yes

• Only actively treat if bleeding
• Haemostatic resus (incl. TXA)

DABIGATRAN:
- Check IIa (thrombin) level
- If life threat bleed::
—> PRAXBIND (idarucimab) 5g over 20mins
—> Dialysis
—> Consider FFP, prothrombinex

RIVAROX/ APIXABAN:
- Check Anti-Xa level
- If life-threat bleed:-
—> Prothrombinex 50units/kg
—> FFP
(andexanet not avail in Aus)

D
Admit all
OBSERVE 12 hours

Question 2

SUPRATHERAPEUTIC WARFARIN:

Answer 2

AC: yes if last dose within 1 hour
_________

NOT BLEEDING (or minor bleed):
- INR <4.5
–> Reduce or omit next dose. Routine INR.
- INR 4.5 - 10
–> Stop. Routine INR. Recommence lower dose once in range.
–> High Risk: 1-2mg PO Vit K
- INR >10
–> Stop. INR within 12 hours. Recommence lower dose once in range.
–> 3-5mg PO/IV Vit K
–> High Risk: 25units/kg Prothrombinex (PPC)
_________

BLEEDING:
- LIFE-THREATENING
Stop warfarin
–> 1- VITAMIN K 10mg IV
–> 2- Prothrombinex 50 units/kg
AND
–> 3- FFP 1 unit (or 15ml/kg if no prothrombinex*)
- 20-minutely INR

-SIGNIFICANT
As above, but without the routine FFP.
__________

Look for reasons for STx

Question 3

WARFARIN OD in Kids:

Answer 3

<0.5mg/kg
- Home

>0.5mg/kg
- 10mg PO Vit K prophylaxis, home.
- No INR or follow up.

Question 4

WARFARIN OD in adults not on Warfarin:

Answer 4

• Vit K, 5mg BD, PO, 2 days
• INR won’t rise for 24 hours, pointless to check on presentation.
• Home for INR at 48 hours

Risk of bleeding usually only from >2mg/kg

Question 5

Vit K doses in Warfarin OD/ Supratherapeutic:

Answer 5

Prophylaxis in kids with Warfarin OD:
–> 5mg PO stat
Prophylaxis in adults with Warfarin OD:
–> 5 mg BD PO for 5 days

Supratherapeutic INR:
- 4.5 - 10 and high risk: 1-2mg PO
- >10: 3-5mg
- Significant/ life-threat bleed: 10mg PO/IV