Anticoagulation Flashcards
LM is a 65 y/o female admitted to the hospital after undergoing a right lower extremity thrombectomy.
Vital Signs: BP 92/60 mmHG, HR 115, Ht 66 in, Wt 69 kg
Current Inpatient Medications:
5% dextrose in water infusing at 50 mL/hr
Heparin 25,000 units/250 mL infusing at 18 units/kg/hr
The pharmacist is notified that LM has an active retroperitoneal hemorrhage. How much protamine should this patient receive based on her heparin drip rate over the last 2 hours?
a. 11 mg
b. 25 mg
c. 37 mg
d. 46 mg
e. 55 mg
b
1 mg of protamine reverses 100 units of IV UFH.
PR is a 76 y/o female who reports occasional episodes of dizziness and a racing heartbeat after her evening walks over the past few weeks. An ECG reveals an “irregularly irregular” HR and rhythm. She’s subsequently diagnosed with nonvalvular atrial fibrillation. There are no other significant lab or physical exam findings.
PMH: HTN, hypothyroidism
SH: Smokes cigarettes (1 cigarette after dinner), doesn’t drink alcohol
Allergies: None
Meds: Levothyroxine 25 mcg PO QAM, Lotrel 10/20 mg PO QAM
Vital Signs: BP 132/82, HR 96, Ht 64”, Wt 130 lbs
Which of the following meds should be added to the pt’s regimen?
a. Aspirin/dipyridamole
b. Clopidogrel
c. Nimodipine
d. Rivaroxaban
e. Warfarin (INR goal 1.5-2.5)
d
This pt’s CHA(2)DS(2)-VASc score is 4
-female = 1
-HTN = 1
-Older than 75 = 1
Females with a score of >/= 3 require anticoagulation, preferably with a DOAC d/t a more favorable risk-benefit profile compared to warfarin.
HL is taking Xarelto 15 mg PO BID at 9 AM and 9 PM for a newly diagnosed DVT. HL calls the pharmacy at 4 PM and states that he forgot to take his 9 AM dose of Xarelto. What should the pharmacist instruct HL to do?
a. Take half of a 15 mg tablet now and resume scheduled dosing at 9 PM tonight
b. Take one 15 mg tablet now and resume scheduled dosing at 9 PM tonight
c. Take one 15 mg tablet now, omit the 9 PM dose tonight, and resume scheduled dosing at 9 AM tomorrow
d. Take one and half 15 mg tablets at 9 PM tonight and resume scheduled dosing at 9 AM tomorrow
e. Take nothing now and resume scheduled dosing at 9 PM tonight
b
Dosing of rivaroxaban for VTE is 15 mg PO BID for 21 days, followed by 20 mg PO QD with missed doses taken as follows:
-15 mg tablet PO BID: Take the missed dose immediately. Two tabs may be taken at the same time.
-20 mg tab PO QD: Take the dose immediately. If it’s already the next day, skip the missed dose. Two 20 mg tabs shouldn’t be taken on the same day.
BW is a 25 y/o female with antiphospholipid syndrome admitted for a pulmonary embolism. She was started on warfarin (goal INR: 2-3) + enoxaparin on June 24th. Enoxaparin was discontinued on July 1st at the time of hospital discharge.
Date - Warfarin Dose - INR:
6/24 - 10 mg - 1.4
6/25 - 5 mg - 1.6
6/26 - 5 mg - 1.7
6/27 - 5 mg - 2.0
6/28 - 5 mg - 1.8
6/29 - 5 mg - 2.2
6/30 - 5 mg - 2.4
7/1 - 5 mg - 2.3
On which date should enoxaparin have been discontinued?
a. 6/24; enoxaparin isn’t indicated in this pt
b. 6/27
c. 6/28
d. 6/29
e. 6/30
e
The bridging period must last:
-A minimum of 5 days
AND
-Until the INR is therapeutic for at least 24 hours
A pharmacy technician trainee is preparing a batch of heparin bags based on the standard compounding formula provided below.
Compounding Recipe UFH 25,000 units/250 mL
UFH (10,000 units/10 mL) - 25 mL
5% Dextrose in water (250 mL bag)
During final verification, the pharmacist notices that 25 mL of UFH 10,000 units/mL was used while compounding. Which of the following would most likely occur if this bag of heparin is administered to a pt?
a. Subtherapeutic aPPT leading to an increased risk of bleeding
b. Subtherapeutic activated aPPT leading to an increased risk of clotting
c. Supratherapeutic aPTT leading to an increased risk of bleeding
d. Supratherapeutic aPTT leading an increased risk of bleeding
e. Therapeutic aPTT time leading to an appropriate level of anticoagulation
c
A 42 y/o female presents to the anticoagulation clinic for warfarin management. She has been taking 1.5 tabs of warfarin 5 mg daily for 2 months for a mechanical aortic valve. Her INR is 3.8 today.
Clinic Warfarin Protocol
INR - Instructions:
< 1.5 - Increase weekly dose 10-20%
1.5-1.9 - Increase weekly dose 5-10%
2-3 - No change
3.1-4 - Hold 1 dose and decrease weekly dose by 10%
5.1-9 - Prescriber order required; hold 2 doses and decrease weekly dose by 10-20%
> 9 - Contact prescriber for urgent evaluation
Which of the following regimens will adhere to the clinic’s warfarin protocol?
a. Prescribe 4 mg tabs: take 1 tab on Monday and Wednesday and 1.5 tabs on Sun, Tues, Thurs, Fri, Sat
b. Prescribe 5 tabs: take 1 tab on Mon and Wed and 1.5 tabs on Sun, Tues, Thurs, Fri, Sat
c. Prescribe 6 mg tabs: take 1 tab daily
d. Prescribe 6 mg tabs: take 1.5 tabs daily
e. Prescribe 10 mg tabs: take 1 tab Mon, Tues, Wed, Thurs
b
Select the correct MOA for Pradaxa:
a. Oral direct factor IIa inhibitor
b. Injectable direct thrombin inhibitor
c. Vitamin K antagonist
d. Oral factor Xa inhibitor
e. Inhibits factor Xa and factor IIa via antithrombin
a
GF is a 54 y/o female with a mechanical mitral valve, HTN, and GERD. What is the correct INR target for GF?
a. 3.0 - 4.0
b. 2.5 - 3.5
c. 2.0 - 3.0
d. 1.5 - 2.5
e. Warfarin isn’t indicated for this pt
b
MG is a 43 y/o male with an appointment at the anticoagulation clinic. He’s usually well controlled on a warfarin regimen of 7.5 mg five days per week (S, M, W, F, Sat) and 5 mg two days per week (T, Th). He reports that he completed a 10-day course of levofloxacin for an URTI this morning. His INR is elevated today at 3.5 (goal INR 2-3). He has no noticeable bleeding. In addition to holding warfarin, which of the following is the most appropriate tx?
a. 4-factor prothrombin complex concentrate and phytonadione 10 mg IV
b. Phytonadione 2.5 mg PO only
c. Phytonadione 1 mg by IM only
d. Phytonadione 10 mg by IV only
e. No additional therapy is required
e
INR - Bleeding - Tx:
< 4.5 - none or minimal - hold or decrease warfarin dose
4.5-10 - none or minimal - hold 1-2 doses of warfarin and resume when INR is therapeutic. Resume warfarin at a lower dose when INR is therapeutic
> 10 - none or minimal - hold warfarin, administer 2.5-5 mg PO vitamin K, and resume warfarin at lower dose when INR is therapeutic
Any - serious or life threatening - hold warfarin and administer IV vitamin K 5-10 mg and 4-PCC
A 45 y/o male is starting Xarelto for an acute DVT of the LLE. Which of the following meds should be started on day 1 along with Xarelto?
a. Aspirin
b. Enoxaparin
c. Fondaparinux
d. Warfarin
e. No other med is required
e
Which of the following should be discussed with a pt receiving a new Rx for Pradaxa?
a. The generic name of this med is rivaroxaban.
b. This med must be kept in the original container. Do not put into a pill box.
c. This med requires periodic lab monitoring.
d. This med is used to prevent blood clots around your artificial heart valve.
e. Take this med with food.
b
Discard original container after 4 months from opening.
A 64 y/o male is 3 days s/p total hip arhtroplasty. He will be discharged with a new Rx for Lovenox 40 mg SQ daily. Which of the following instructions should the pharmacist provide during the discharge counseling session?
a. Remove the needle cap by pulling it straight off the syringe
b. Expel the air bubble from the syringe prior to the injection
c. Give the injection at least 2 inches away from the umbilicus
d. Insert the entire length of the needle into the skin at a 15-degree angle
e. Massage the injection site for about 10 seconds after the injection
a, c
CD is a 66 y/o male who presents to the ED with a painful and swollen right leg. The pt reports that the pain and swelling began yesterday after he drove for 14 hours.
PMH: HTN, obesity, CKD
Home Meds: Amlopidine 5 mg PO daily, lisinopril 10 mg PO daily
SCr: 1.7 g/dL
Ultrasound: RLE DVT
What is the correct dose of PO apixaban for CD?
a. 2.5 mg BID
b. 5 mg daily
c. 20 mg daily
d. 10 mg BID x 7 days, then 5 mg BID
e. 15 mg BID x 21 days, then 20 mg daily
d
Which of the following meds will enhance warfarin’s metabolism?
a. Rifampin
b. Cimetidine
c. St. John’s wort
d. Amiodarone
e. Phenytoin
a, c, e
SK is a 55 y/o female with a mechanical aortic heart valve, diabetes, and osteoporosis. What is the recommended therapeutic INR range of warfarin in this pt?
a. 3.5-4.5
b. 2.5-3.5
c. 2-3
d. 1.5-2.5
e. 3-4
c
-Pts with a mechanical aortic heart valve should have an INR between 2-3
-Pts with 2 mechanical valves or a single mechanical mitral valve require a higher INR goal (2.5-3.5)
What is the antidote for unfractionated heparin?
a. 4-factor prothrombin complex concentrate
b. Idarucizumab
c. Platelets
d. Protamine sulfate
e. Tranexamic acid
d
