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NAPLEx > Anticoagulation > Flashcards

Anticoagulation Flashcards

1
Q

why DOAC over warfarin

A
  • less DDI, less or comparable bleeding, shorter duration of action compared to warfarin
  • DOAC dosed based on indication and kidney/liver function, not INR
  • DOAC preferred for stroke prevention in AF,
    —-> but if moderate to severe mitral stenosis or a mechanical heart valve, use warfarin
  • DOAC for VTE tx
    —-> unless pt has antiphospholipid syndrome use warfarin
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2
Q

antithrombin (AT)

A

body’s natural anticoagulants. it inactivates thrombin (factor IIa) and other proteases (like factor Xa).

UFH, LMWH< fonda[aromix bind to AT, cause conformational change which increases AT activity by 1,000- fold.

LMWH inhibits factors Xa more than UFH.

Fondaparinux binds to AT resulting in selective inhibition of factor Xa

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3
Q

inhibiting factor Xa directly

A

apixaban (eliquis)
rivaroxaban (xarelto)

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4
Q

Direct thrombin inhibitors

A

IV DTIs (e.g. agratroban) are great, do not cross-react with HIT antibodies. Dabigatran is oral DTI

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5
Q

UFH

A
  • fatal med errors can occur, verify concentration,
  • check anti-Xa level every 6 hrs , until therapeutic
  • decrease in platelets >50% from baseline suggest possible HIT
  • HIT antibodies have cross-sensitivity with LMWH
  • heparin lock-flushes (HepFlush) are used to keep IV lines open
  • hyperkalemia

-monitor hematocrit, hemoglobin, aPTT, and platelets

  • antidote: protamine
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6
Q

Enoxaparin

A

Leovenox
- dose adjustment after <30….
- box warning: neuraxial anesthesia (epidural).. or spinal puncture are at risk for hematomas and subsequent paralysis
- does not require monitoring
- antidote: protamine
- do not expel air from syringe prior to injection…90% angle, abdomen 5cm/2” from umbilicus

  • keep in mind it does not require monitoring but extreme body weight (high or low), renal clearance issues, and prego will need monitoring cause of altered pharmacokinetics
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7
Q

Management of HIT

A
  • stop heparin and LMWH
  • warfarin should be d/c and vitamin k started
  • for immediate tx use non-heparin anticoagulant (e.g. argatroban)
  • do not start warfarin until platelet received >150,000, warfarin at a lower dose- 5mg max, overlap with non-heparin anticoagulant for 5 days min, until INR within range for 24 hrs. keep in mind argatroban can increase INR,
  • if urgent cardiac surgery such as PCI, bivalirudin preferred
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8
Q

Apixaban

A

Eliquis
nonvalvular AF 5mg BID
DVT/PE 10mgBID x7days, then 5mgBID
- not recommended in prosthetic heart vales or antiphospholipid syndrome
- antidont andexanet alfa
- can be crushed, mixed in water, DW or apple juice…. put on apple sauce for suspended in water for NG tube too.
-neuraxial anesthesia (epidural).. or spinal puncture are at risk for hematomas and subsequent paralysis

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9
Q

Rivaroxaban

A

Xarelto
nonvalvular AF (stroke prophylaxis)
- CrCl >50 20mg w/ evening meals
- CrCl 15-50 15mg w/eveing meals
- CrCL <15 avoid use
DVT/PE
- 15mg BID, then 20daily
- CrCl< 30 avoid use
- put on apple sauce for suspended in water for NG tube
- not recommended in prosthetic heart vales or antiphospholipid syndrome
- antidont andexanet alfa
- neuraxial anesthesia (epidural).. or spinal puncture are at risk for hematomas and subsequent paralysis

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10
Q

Edoxaban

A

Savaysa
- reduced efficacy in nonvalvular AF of pt CrCL >95- do not use
- put on apple sauce for suspended in water for NG tube
- neuraxial anesthesia (epidural).. or spinal puncture are at risk for hematomas and subsequent paralysis

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11
Q

Fondaparinux

A

Arixtra
- contra in renal <30 CrCl
- neuraxial anesthesia (epidural).. or spinal puncture are at risk for hematomas and subsequent paralysis

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12
Q

Conversion between anticoagulants
from warfarin to oral anticoagulants

A

stop warfarin and convert to:
Rivaroxaban INR <3
Edoxaban INR <2.5
Abixaban INR <2
Dabigatran INR <2

READ

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13
Q

Conversion between anticoagulants
from oral Xa anticoagulants to warfarin

A

stop Xa inhibitors, start parental anticoagulants and warfarin at next scheduled dose

Endoxaban only: refer to package insert

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14
Q

Conversion between anticoagulants
from dabigatran to warfarin

A

start warfarin 1-3 days before stopping dabigatran (determine renal function… and refer to package insert)

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15
Q

Dabigatran

A

Paradaxa
- oral direct thrombin inhibitor
- neuraxial anesthesia (epidural).. or spinal puncture are at risk for hematomas and subsequent paralysis
- contra in pt with mechanical prosthetic heart valve
- antidote: idarucizumab (praxbind)
- swallow capsules do not admin by NG tube
- missed dose take immediately unless within 6 hours of next dose

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16
Q

argatroban

A

IV direct thrombin inhibitors
- safe with HIT

17
Q

Bivalirudin

A

angiomax
- IV direct thrombin inhibitors
- safe with HIT
- use this if undergoing PCO in pt with HIT risk
-

18
Q

Warfarin

A

Coumadin, Jantoven
- do not double the dose or try to make up for the missed dose..
- contra prego unless pt w/ mechanical heart valves
- contra in tissue necrosis/gangrene, HIT

  • highly protein bound. pt with hypoalbumin will have issues…
  • presence of CYP2C9*2 or *3 and/or VKORC1 polymorphism gene may increase bleeding risk
  • antidote: vitamin K
19
Q

Warfarin INR goal

A

INR 2-3: most indications (VTE, AF, bioprosthetic mitral valve, mechanical aortic valve, antiphospholipid syndrome)

INR 2.5-3.5: high-risk indications (mechanical mitral valve or 2 mechanical heart valves)

20
Q

warfarin CYP2C9 inducers

A

warfarin is a major substrate of CYP2C9, inducers decrease INR (includes carbamazepine, phenobarbital, phenytoin, st johns’s wart, rifampin, aprepitant, bosentan, primidone, licorice)

21
Q

warfarin CYP2C9 inhibitors

A

amiodarone, azole antifungals, capecitabine, cimentidine, fluvastatin, fluvoxamine, metronidazole, TMP/SMX, zariflukast, tamoxifen, tigecycline

when starting amiodarone, decrease the dose of warfarin by 30-50%

22
Q

general increased bleed risk with

A

NSAID, SSRIs, SNRIs

increased colting risk with estrogen, SERMs

23
Q

supplements and warfarin

A
  • increased bleed risk with “the 5 G’s” (garlic, ginger, ginkgo, ginseng, glucosamine) dong quai, vitamin E, fish oils @high dose, willow bark, wintergreen oil
  • decreased effectiveness: green tea, coq10, st. john’s wort, alfalfa

foods w/ high vitamin K: spinach, broccoli, brussle sprouts, cabbage, beef liver, Kale

24
Q

Warfarin tablet color

A

Pink 1mg
Lavender 2 mg
Green 2.5 mg
Brown/tan 3 mg
Blue 4 mg
Peach 5 mg
Teal 6 mg
Yellow 7.5 mg
White 10 mg

Please Let Greg Brown Bring Peaches To Your Wedding

25
Q

Warfarin Use

A

healthy outpatient, start less than 10mg for the first two days, then adjust per INR values

in pt with acute DVT/PE start warfarin on the same day as parenteral anticoagulentls… continue both for minimum 5 day, and until INR >2 for at least 24 hr

26
Q

Protamine sulfate

A

IV UFH reversal- 1g will reverse 100 units of heparin (50mg max, heparin half-life is 2-2.5hrs)

LMWH reversal- 1mg protamine per 1mg of enoxaparin

27
Q

Idarucizumab

A

Paxbind
reversal for dabigatran

28
Q

Andexanet Alfa

A

Andexxa
reversal for apixaban and rivaroxaban

29
Q

warfarin reversal

A

Vitamin K or phytonadione (mephyton): PO/IV, protect from light!,

four-factor prothrombin (Kcentra): Factors II, VII, IX, X, protein C, protein S- admin with vitamin K

there factor prothrombin (Profilnine): factors II, IX, and X. admin with vitamin K.

FActor VIIa Recombinant (NovoSeven RT)…off label

30
Q

warfarin over anticoagulation
above therapeutic bu INR <4.5

A

reduce or skip warfarin dose
monitor INR

31
Q

warfarin over anticoagulation
INR 4.5-10

A

vitamin K is not needed if there is no evidence of bleeding. Hold 1-2 doses of warfarin

vitamin K may be used if urgent surgery is needed or bleeding risk is high <5mg, 1-2mg in 24hr…

32
Q

warfarin over anticoagulation
INR >10

A

hold warfarin give oral vitamin K .25-5mg even if not bleeding. Monitor INR, resume at lower dose when INRO therapeutic

33
Q

warfarin over anticoagulation
major bleed

A

give vitamin K 5-10mg by slow IV injection and four-factor prothrombin complex.

34
Q

warfarin and surgery

A

warfarin: stop 5 days before surgery
LMWH: 24 hrs before
UFH: 4-6 hours before

35
Q

anticoagulation for pt w/AF

A
  • AF>48hr, anticoagulation for at least 3 weeks prior to and 4 weeks after cardioversion
  • AF<48hrs, start full therapeutic anticoagulation at presentation and continue full anticoagulation at least 4 weeks after normal sinus rhythm

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