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NAPLEX Prep > Anticoagulation > Flashcards

Anticoagulation Flashcards

1
Q

UFH MOA

A

binds to antithrombin (AT) and accelerates its ability to inactivate thrombin (factor IIa) and factor Xa

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2
Q

UFH dosing:
VTE prophylaxis

A

5,000 units SC Q8-12H

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3
Q

UFH dosing:
VTE treatment

A

80 units/kg IV bolus
18 units/kg/hr infusion

use total body weight

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4
Q

UFH dosing:
ACS/STEMI treatment

A

60 units/kg IV bolus
12 units/kg/hr infusion

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5
Q

UFH CI

A

uncontrolled active bleed
some products contain benzyl alcohol -> do not use in neonates, infants, pregnancy, or breastfeeding

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6
Q

UFH ADE

A

Bleeding
HIT
hyperkalemia

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7
Q

UFH Monitoring

A

Platelets, Hgb, Hct

aPTT or anti-Xa level:
- 6 hrs after initiation
- every 6 hrs until therapeutic
- then Q24H & with every dose change

aPTT (1.5-2.5 x control)
anti-Xa level (0.3-0.7 units/mL)

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8
Q

Heparin lock-flushes (HepFlush)

A

only used to keep IV lines open

look alike / sound alike with UFH -> DO NOT MISTAKE ONE FOR THE OTHER

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9
Q

UFH & LMWH antidote

A

protamine

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10
Q

LMWHs MOA

A

bind to AT and accelerate its ability to inactivate factor Xa and factor IIa. Anti-factor Xa > Anti-factor IIa

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11
Q

Lovenox

A

Enoxaparin
LMWH

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12
Q

LMWH Boxed Warnings

A

Risk of hematomas & paralysis in pts receiving neuraxial anesthesia (epidural, spinal) or undergoing spinal puncture

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13
Q

LMWH CI

A

Hx of HIT (antibodies have cross-sensitivity)

active major bleed

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14
Q

LMWH ADE

A

Bleeding
Anemia
Injection site reactions
Thrombocytopenia (inc HIT)

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15
Q

LMWH monitoring

A

Platelets, Hgb, Hct, SCr

anti-Xa monitoring not usually needed
- exceptions: pregnancy, renal insufficiency, obesity, low body weight

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16
Q

LMWH dosing:
VTE prophylaxis

A

30mg SC Q12H
OR
40mg SC daily

CrCl < 30 -> 30mg SC daily

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17
Q

LMWH dosing:
VTE treatment
&
UA / NSTEMI treatment

A

1 mg/kg SC Q12H

inpatient VTE treatment only: 1.5 mg/kg SC daily

CrCl < 30 -> 1 mg/kg SC daily

use total body weight for dosing

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18
Q

LMWH dosing:
STEMI treatment (< 75 years old)

A

30mg IV bolus + a 1 mg/kg SC dose
-> 1 mg/kg SC Q12H

CrCl < 30 -> same as above but 1mg/kg SC DAILY

use total body weight for dosing

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19
Q

LMWH dosing:
STEMI treatment (75 years and older)

A

NO BOLUS
0.75 mg/kg SC Q12H

CrCl < 30 -> 1 mg/kg SC daily

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20
Q

4 Ts Score

A

used to assess the probability of HIT
- Thrombocytopenia: unexplained > 50% drop in Plt count from baseline
- Timing: Plt count drop 5-10 days after starting heparin or within hrs if pt was exposed to heparin in the past 3 months
- Thrombosis: new, suspected, or confirmed thrombosis
- oTher causes: inability to identify other causes

21
Q

Management of HIT complicated by thrombosis (HITT)

A
  • stop all forms of heparin & LMWH
  • if pt is on warfarin -> DC warfarin and admin vitamin K. Do not restart warfarin until platelets > 150,000
  • rapid acting non-heparin anticoagulants (ex. argatroban)
  • if urgent surgery or PCI is required -> Bivalirudin is the preferred anticoagulant
22
Q

Eliquis

A

Apixaban
Class: DOAC
Tablet

23
Q

Eliquis dosing:
Nonvalvular AF

A

5 mg PO BID

2.5mg PO BID if 2 of the following:
- age > 80
- weight < 60kg
- SCr > 1.5

24
Q

Eliquis dosing:
DVT/PE Treatment

A

10mg PO BID x 7 days ->
then 5mg PO BID

25
Xarelto
Rivaroxaban Class: DOAC tablet, oral suspension doses 15mg or higher must be taken with food
26
Xarelto dosing: Nonvalvular AF (stroke prophylaxis)
CrCl > 50: 20mg PO daily CrCl 15-50: 15mg PO daily CrCl < 15: avoid use
27
Xarelto dosing: DVT/PE treatment
15mg PO BID x 21d -> then 20mg PO daily with food CrCl < 30: avoid use
28
Savaysa
Edoxaban Class: DOAC Tablet
29
DOAC safety/ADE/monitoring
Boxed warning: - risk of hematoma and paralysis in pts receiving neuraxial anesthesia (spinal, epidural) or undergoing spinal puncture CI: - active bleed Warnings: - not recommended with prosthetic heart valves Monitoring: - no efficacy monitoring required Antidote: - Andexanet alfa (Adexxa) for apixaban & rivaroxaban
30
Arixtra
Fondaparinux Injectable indirect factor Xa inhibitor SC injection BW: - hematoma & paralysis risk in pts getting epidural or spinal injections CI: - severe renal impairment (CrCl < 30) Off label indication for HIT
31
Factor Xa inhibitor DDI
Additive bleed risk Apixaban & Rivaroxaban: - avoid use with strong inducers of 3A4 and P-gp (carbamazepine, phenytoin, rifaximin, St. John's wort)
32
Conversion from Warfarin to another PO anticoagulant: READ
Stop warfarin and convert to: Rivaroxaban when INR < 3 Edoxaban when INR < 2.5 Apixaban when INR < 2 Dabigatran when INR < 2
33
Conversion from oral Xa inhibitors to warfarin
stop Xa inhibitor start parenteral anticoagulant and warfarin at next scheduled dose
34
Conversion from dabigatran to warfarin
Start warfarin 1-3 days before stopping dabigatran (determined by renal function, refer to dabigatran labeling)
35
Pradaxa
Dabigatran Oral direct thrombin inhibitor Capsule, oral packet (pellets)
36
Pradaxa: safety/ADE/monitoring
Boxed warning: - risk of hematoma & paralysis with spinal or epidural injections CI: - active bleed - mechanical prosthetic heart valve ADE: - dyspepsia, bleeding Monitoring: - no efficacy monitoring required Notes: - dispense in original container, discard 4 months after opening - swallow capsules whole - do not admin by NG tube
37
Praxbind
Idarucizumab Dabigatran antidote
38
Pradaxa dosing: Nonvalvular AF (stroke prophylaxis)
150 mg BID CrCl 15-30: 75mg BID
39
Pradaxa dosing: DVT/PE treatment & secondary prevention
150mg BID, start after 5-10 days of parenteral anticoagulation CrCl < 30 : avoid use
40
Argatroban
Injectable direct thrombin inhibitor Injection Indicated for HIT and in pts undergoing PCI who are at risk of HIT
41
Angiomax
Bivalirudin Injectable direct thrombin inhibitor Injection Indicated for patients with ACS undergoing PCI, including those with HIT
42
Injectable direct thrombin inhibitors (argatroban, bivalirudin): safety/ADE/monitoring
CI: active bleed ADE: bleeding Monitor: aPTT, Plt, Hgb, Hct, renal function
43
Jantoven, Coumadin
Warfarin
44
Jantoven, Coumadin: Safety/ADE/Monitoring
CI: pregnancy (except with mechanical heart valve) Warnings: - tissue necrosis/gangrene - HIT - inc bleed risk with CYP2C9 *2 or *3 alleles and/or polymorphism of VKORC1 ADE: - bleeding/bruising - skin necrosis - purple toe syndrome Monitoring: - Goal INR 2-3 for most indications - Goal INR 2.5-3.5 for high risk indications (mechanical MITRAL valve, 2 mechanical valves) Notes: - antidote: Vitamin K
45
Warfarin DDI
CYP2C19 inducers dec INR (carbamazepine, phenobarbital, phenytoin, rifampin, St. John's wort) CYP2C19 inhibitors inc INR (amiodarone, azole antifungals, metronidazole, TMP/SMX)
46
Warfarin DDI: CAM / supplements
inc bleed risk: chamomile, chondroitin, dong quai, fish oils, 5 G's (garlic, ginger, gingko, ginseng, glucosamine), Vitamin E, willow bark inc clot risk: St. John's wort, green tea, CoQ10 Vitamin K decreases INR (inc clot risk) -> keep Vit K in diet consistent
47
Warfarin tablet colors: Please Let Greg Brown Bring Peaches To Your Wedding
Pink (1 mg) 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)
48
Foods high in vitamin K
spinach broccoli Brussel sprouts collard greens kale Others: turnip greens, green onion, asparagus, cabbage, cauliflower

NAPLEX Prep (40 decks)

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