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NAPLEX > Anticoagulation > Flashcards

Anticoagulation Flashcards

1
Q

Warfarin inhibits…

A
  • Factor II
  • Factor VII
  • Factor IX
  • Factor X
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2
Q

Direct Xa Inhibitors

A
  • RivaroXAban
  • ApiXAban
  • EdoXAban
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3
Q

Indirect Xa Inhibitor

A

Fondaparinux (SQ)

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4
Q

Heparins and Where They Work

A
  • Unfractionated, UFH (equal Xa and IIa activity)
  • LMWH - Enoxaparin, Dalteparin (More Xa than IIa activity)
  • Work via antithrombin
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5
Q

Direct Thrombin Inhibitors

A
  • IV: Argatroban, Bivalirudin

- PO: Dabigatran

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6
Q

UFH Dosings

A
  • VTE Prophylaxis: 5000u SQ Q8-12H
  • VTE Treatment: 80u/kg bolus IV, 18u/kg/hr infusion (continuous, short half life)
  • ACS/STEMI Tx: 60u/kg IV bolus, infuse 12u/kg/hr
  • TBW for dosing!!!
  • HIT antibodies cross react with LMWH
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7
Q

UFH Information

A
  • SE: HIT (platelets drop >50% from baseline, thrombocytopenia), hyperkalemia, osteoporosis with long-term use
  • Monitor: aPTT and anti-Xa level - check Q6H
  • aPTT should be between 1.5-2.5 * control
  • CAUTION: fatal errors associated with Heparin lock-flushes dosing mix-ups (10x dose. used to keep lines open)
  • Antidote: protamine
  • Unpredictable anticoagulation response
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8
Q

LMWH VTE Dosing

A
  • VTE Prophylaxis: 30 mg SQ Q12H or 40 mg QD
  • VTE Tx: 1 mg/kg SQ Q12H or 1.5 mg/kg SQ QD (inpatient only, pref. anticoag for cancer pts)
  • CrCl < 30: lower dosing option at Q24H
  • TBW for dosing!!!
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9
Q

LMWH STEMI Dosing

A
  • Pts < 75 yo: 30 mg IV bolus + 1 mg/kg SQ dose (then Q12H) Only indication for IV administration
  • CrCl < 30: same as above except dose is given QD instead of Q12H OR 1mg/kg SQ QD with no bolus
  • Patient’s over >=75 yo don’t get bolus
  • TBW for dosing!!!
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10
Q

LMWH Information

A
  • Boxed warnings: neuraxial anesthesia => hematoma and paralysis risk
  • CI: HIT history
  • Anti-Xa monitoring only recommended in pregnancy (obtained 4 hours after SQ dose, peak)
  • Antidote: protamine
  • Don’t expel bubbles from syringe
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11
Q

Apixaban Dosing

A
  • Nonvalvular Afib (NVAF): 5 mg PO BID
  • IF patient is 2 of following: >= 80 yo, BW =< 60 kg, or SCR >=1.5 then 2.5 mg PO BID for Afib
  • DVT/PE Tx: 10 mg PO BID x 7 days then 5 mg PO BID (preferred in pts w/o cancer)
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12
Q

Rivaroxaban Dosing

A
  • Doses >= 15 mg need to be taken with food
  • Take Afib doses with evening meals
  • DVT/PE Tx: 15 mg PO BID x 21 days then 20 mg PO QD with food
  • Avoid use in CrCl < 30
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13
Q

Rivaroxaban Missed Doses

A
  • If taking 15 mg BID, take two tablets immediately to ensure 30 mg/day, then back to scheduled dosing
  • If taking 10/15/20 mg QD: take immediately the same day, otherwise skip
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14
Q

Edoxaban

A
  • Direct Xa Inhibitor
  • Don’t use if CrCl > 95 (reduced efficacy)
  • Start after 5-10 days parenteral anticoagulation
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15
Q

DOAC Information

A
  • Boxed Warning: Neuraxial anesthesia => risk of hematomas/paralysis
  • Not recommended for prosthetic heart valves or antiphospholipid syndrome
  • Antidote: Andexanet alfa (Andexxa) - for Eliquis and Xarelto
  • Avoid taking with bleed risk drugs (SSRIs, SNRIs, NSAIDs, herbals) and CYP3A4i
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16
Q

Fondaparinux

A
  • Indirect Xa Inhibitor
  • Boxed Warning: neuraxial anesthesia => hematoma and paralysis
  • CI: severe renal impairment (CrCl < 30)
17
Q

Warfarin to Oral Anticoagulant

A

Stop Warfarin to switch to:

  • Rivaroxaban when INR < 3
  • Edoxaban when INR =< 2.5
  • Apixaban when INR < 2
  • Dabigatran when INR < 2
18
Q

Oral Anticoagulants to Warfarin

A
  • Overlap Xa with warfarin until INR is therapeutic (for 5 days AND INR >=2 for at least 24 hours)
  • Stop Xa inhibitor and warfarin at next dose
19
Q

Dabigatran to Warfarin

A
  • Start warfarin 1-3 days before stopping dabigatran

- Determined by renal function

20
Q

Dabigatran Dosing

A
  • Direct Thrombin Inhibitor (oral)
  • Dispense in original container and discard 4 mo after opening
  • Swallow capsules whole, NO NG TUBE
  • Take missed dose immediately unless next dose is within 6 hours, then skip (don’t double)
21
Q

Dabigatran Information

A
  • Boxed Warning: Neuraxial anesthesia => hematoma and paralysis
  • CI: mechanical, prosthetic heart valves
  • SE: Dyspepsia, gastritis-like sxs, bleeding (including GI)
  • No monitoring required
  • Antidote: idarucizumab (Praxbind)
22
Q

IV Direct Thrombin Inhibitors

A
  • Argatroban and Bivalirudin (Angiomax)
  • Used in patients at risk for HIT
  • No cross-reaction with HIT-antibodies
  • No antidote
23
Q

Warfarin Dosing

A
  • 10 mg QD for 2 days in health outpatient then adjust per INR
  • Lower dose (=<5 mg) for elderly, malnourished, CYP inhibitors, liver disease, HF, or high risk bleeders
  • S-enantiomer is 2.7-3.8x more potent
  • Don’t double doses if missed, take immediately same day or skip
24
Q

Warfarin Information

A
  • CI: Preggo UNLESS mechanical heart valve
  • Warning: tissue necrosis/gangrene, HIT, presence of CYP2C9 2/3 alleles or VKORC1 gene
  • SE: Purple toe syndrome, bleed, bruise, necrosis
  • Higher INR goal (2.5-3.5) for mechanical mitral or 2+ mechanical valve patients
  • Antidote: Vitamin K
25
Q

CYP2C9 Inducers

A

Decrease INR

  • Rifampin (large decrease)
  • PS PORCS
  • Aprepitant
  • Bosentant
26
Q

CYP2C9 Inhibitors

A

Increase INR (MAT)

  • M: Metronidazole and macrolides
  • A: Amiodarone and azoles (Fluconazole)
  • T: TMP/SMX
27
Q

Warfarin DDI

A
  • NSAIDs, antiplatelet agents (clopidogrel), other anticoagulants, and SSRIs/SNRIs increase bleeding risk but not INR
  • Estrogen and SERMs increase clotting risk
28
Q

Natural Medicines + Warfarin

A

INCREASE bleeding risk

  • 5 Gs (garlic, ginseng, ginkgo, ginger, and glucosamine)
  • Vitamine E
  • Dong quai
  • Fish oils (high dose)
  • Willow bark (natural salicylate)
  • Wintergreen oil

DECREASES Warfarin Efficacy
-St. John’s Wort

29
Q

Protamine

A
  • Antidote for UFH/LMWH
  • 1mg of protamine reverses ~100u of heparin
  • Reverse amount given in last 2-2.5 hours
  • Max dose: 50 mg
  • 1:1 for LMWH, only reverse last 8 hours
30
Q

Kcentra

A 
-Four Factor Prothrombin
Contains:
-Factor II
-Factor VII
-Factor IX
-Factor X
-Protein C
-Protein S

-Administer with Vitamin K (usually IV) for warfarin reversal with major bleeding

31
Q

Phytonadione

A
  • Vitamin K, warfarin antidote
  • Given IV or PO (1-10 mg)
  • Boxed warning: hypersensitivity (anaphylaxis)
  • Requires light protection
  • SQ has variable absorption and IM has risk of hematoma
  • Don’t reverse until INR > 10 and/or bleed (w/o bleed use oral)
32
Q

HIT

A
  • Diagnosis: PLT drop >50%
  • IgG reaction
  • Risk for UFH and LMWH (cross-reactive between meds)
33
Q

Praxbind

A
  • Idarucizumab

- Antidote for Pradaxa (dabigatran)

34
Q

Angiomax

A
  • Bivalidurin
  • Injectable direct thrombin inhibitor (IV)
  • Mainly used/seen in cardiac/cath. labs
35
Q

Warfarin Colors

A 
Please Let Greg Brown Bring Peaches To Your Wedding:
P: Pink - 1 mg
L: Lavender - 2 mg
G: Green - 2.5 mg
B: Brown - 3 mg
B: Blue - 4 mg
P: Peach - 5 mg
T: Teal - 6 mg
Y: Yellow - 7.5 mg
W: White - 10 mg
36
Q

Andexxa

A
  • Andexamet alfa

- Antidote for xarelto and rivaroxaban (ONLY)

NAPLEX (59 decks)

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