Anticoagulation Flashcards
What are anticoagulants commonly used for?
ACS
prevention of cardioembolic stroke
prevention/treatent of VTE (DVT/PE)
When do you use DOACs?
when CHADSVASC score >2 in men or >3 women
When would you use warfarin vs DOAC?
moderate to severe mitral stenosis or a mechanical heart valve
Use DOACs for VTE treatment BUT if the patient has cancer use:
LMWH
Which anticoagulants bind to antithrombin to indirectly inhibit Xa?
UFH equal Xa IIa inhibition
LMWH Xa>IIa
fondapurinox binds to AT to inhibit Xa
What is the drug of choice in HIT?
injectable argatroban
Binds to AT which then inactivates thrombin (Factor IIA) and factor Xa and prevents the conversion of fibrinogen to fibrin
UFH
ok in renal impairment
What is the prophylaxis dose of UFH in VTE presentation?
UFH 5000u SC Q8-12H
What is the treatment dose of UFH in VTE treatment?
80u/kg IV bolus; 18u/kg/hr infusion
TBW
What is the treatment dose of UFH in ACS/STEMI
60u/kg IV bolus, infuse 12u/kg/hr
TBW
Binds to AT which inactivates factor Xa >factor IIA
LMWH
What is the prophylaxis dose of VTE for enoxaparin?
30mg BID or 40mg QD
<30mL/min = 30mg QD
What is the treatment of VTE and UA/NSTEMI dose of enoxaparin?
1mg/kg BID
TBW
What is the treatment for STEMI of enoxaparin?
<75 = 30mg IV bolus + 1mg/kg SC dose
> 75 no bolus
Brand: Fragmin
generic: dalteparin
When do you restart warfarin after HIT?
when platelets recover to >150
What is Apixibans dose for nonvalvular Afib/stroke prophylaxis
5mg BID
What is Apixibans dose for treatment of DVT/PE
10mg PO BID x 7 days
then 5mg PO BID
The patient is receiving stroke prophylaxis but the patient >80 and bodyweight is <60kg /Scr >1.5. what’s her apixaban dose?
(only need two of these factors)
2.5mg BID
Which DOAC is reduced efficacy when crcl>95
edoxaban
Brand: Xarelto
generic: rivaroxaban
Doses >___ of Xarelto require food
> 15mg
What is the dose of Xarelto for treatment of DVT/PE
15mg PO BID x 21 days
then 20mg PO daily
<30ml/min = avoid use
if the dose of Xarelto is missed how should it be taken
ok to double up to ensure 30mg is taken
*if taking 10, 15, 20mg once daily, immediately on the same day, otherwise skip
When do you start edoxaban for the treatment of DVT/PE?
60mg daily
start after 5-10 days of IV anticoagulation
What is the antidote for apixaban and rivaroxaban?
andexanet alfa (Andexxa)
Brand: Arixta
generic: fondapurinox
When a patient has HIT but is going in for a cardiac Cath lab what do you use?
bivalrudin (Angiomax)
A patient is on an NG tube and is on dabigatran, what do you do?
can’t administer, swallow capsules whole!
What DOAC has side effects:
dyspepsia, gastritis-like symptoms
dabigatran
When is the goal for warfarin 2.5-3.5?
high risk indications
mechanical mitral valve
or two mechanical heart valves (prosthetic)
What are the tablet colors and strength?
PLGBBPTYW
Please Let Greg Brown Bring Peaches To Your Wedding
pink-1 lavender-2 green - 2.5 brown/tan-3 blue-4 peach-5 teal-6 yellow-7.5 white-10
Foods high in vitamin K?
broccoli brussel sporouts cabbage spinach tea
What drugs increase warfarin?
amiodarone
fluconazle
metronidazole
bactrim
what drugs decrease warfarin?
rifampin
carbamazepine
SNRIs, SSRIs, NSAIDs how do they effect warfarin?
increase bleeding risk but the INR may not be increased
In healthy outpatients, the initial starting dose of warfarin should be
10mg daily for the first two days then adjust per INR
how do you bridge warfarin?
acute DVT/PE
start warfarin on the same day at the IV AC (enoxaparin or UFH), and continue both anticoagulants for a minimum of 5 days until the INR >2 for at LEAST 24 hours
1mg of Protamine sulfate will reverse how much heparin?
100units
max dose 50mg
1mg per 1mg enoxaparin
Brand: Mephyton
generic: vitamin K or phytonadione
PO/IV
What do you administer with Kcentra?
vitamin K
INR about therapeutic range but <4.5 without bleeding
reduce or skip warfarin dose, monitor INR
INR of 4.5-10 without bleeding
hold 1-2 doses of warfarin
INR >10 without leeding
hold warfarin, give PO vitamin K 2.5-5mg even if not bleeding
MAJOR bleeding
give vitamin K 5-10mg by slow IV and four factor prothrombin complex concentrate (Kcentra)
Discontine LMWH how many days before surgery
24 hours
What are risk factor for DVT?
surgery major trauma immobility cancer previous VTE pregnancy SER
Anticoagulation for patients with AFIB who will undergo cardio version
Afib >48 hours or unknown duration:
anticoagulation (if warfarin target INR 2-3) for at least 3 weeks PRIOR to and 4 weeks AFTER cardio version when NSR is restored
Anticoagulation for patients with AFIB who will undergo cardio version
Afib <48 hours
start full therapeutic anticoagulation at presentation, do cardio version and continue full anticoagulation for at least FOUR weeks while patient is in NSR
What is in the CHADSCASC score?
CHF HTN age >75 (2 points) diabetes prior stroke (2 points) prior MI, PAD age 65-74 female
What is the AC of choice in pregnancy?
LMWH >UFH
*anti Xa levels are recommended to monitor therapy
Do you expel the air bubble in the syringe prior to injection?
no!
& DO NOT RUB THE SITE OF INJECTION
