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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
Q

Xarelto

A

Rivaroxaban
Class: DOAC
tablet, oral suspension

doses 15mg or higher must be taken with food

26
Q

Xarelto dosing:
Nonvalvular AF (stroke prophylaxis)

A

CrCl > 50: 20mg PO daily
CrCl 15-50: 15mg PO daily
CrCl < 15: avoid use

27
Q

Xarelto dosing:
DVT/PE treatment

A

15mg PO BID x 21d ->
then 20mg PO daily with food

CrCl < 30: avoid use

28
Q

Savaysa

A

Edoxaban
Class: DOAC
Tablet

29
Q

DOAC safety/ADE/monitoring

A

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
Q

Arixtra

A

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
Q

Factor Xa inhibitor DDI

A

Additive bleed risk
Apixaban & Rivaroxaban:
- avoid use with strong inducers of 3A4 and P-gp (carbamazepine, phenytoin, rifaximin, St. John’s wort)

32
Q

Conversion from Warfarin to another PO anticoagulant:
READ

A

Stop warfarin and convert to:
Rivaroxaban when INR < 3
Edoxaban when INR < 2.5
Apixaban when INR < 2
Dabigatran when INR < 2

33
Q

Conversion from oral Xa inhibitors to warfarin

A

stop Xa inhibitor
start parenteral anticoagulant and warfarin at next scheduled dose

34
Q

Conversion from dabigatran to warfarin

A

Start warfarin 1-3 days before stopping dabigatran (determined by renal function, refer to dabigatran labeling)

35
Q

Pradaxa

A

Dabigatran
Oral direct thrombin inhibitor
Capsule, oral packet (pellets)

36
Q

Pradaxa:
safety/ADE/monitoring

A

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
Q

Praxbind

A

Idarucizumab
Dabigatran antidote

38
Q

Pradaxa dosing:
Nonvalvular AF (stroke prophylaxis)

A

150 mg BID

CrCl 15-30: 75mg BID

39
Q

Pradaxa dosing:
DVT/PE treatment & secondary prevention

A

150mg BID, start after 5-10 days of parenteral anticoagulation

CrCl < 30 : avoid use

40
Q

Argatroban

A

Injectable direct thrombin inhibitor
Injection
Indicated for HIT and in pts undergoing PCI who are at risk of HIT

41
Q

Angiomax

A

Bivalirudin
Injectable direct thrombin inhibitor
Injection
Indicated for patients with ACS undergoing PCI, including those with HIT

42
Q

Injectable direct thrombin inhibitors (argatroban, bivalirudin):
safety/ADE/monitoring

A

CI: active bleed
ADE: bleeding
Monitor: aPTT, Plt, Hgb, Hct, renal function

43
Q

Jantoven, Coumadin

A

Warfarin

44
Q

Jantoven, Coumadin:
Safety/ADE/Monitoring

A

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
Q

Warfarin DDI

A

CYP2C19 inducers dec INR (carbamazepine, phenobarbital, phenytoin, rifampin, St. John’s wort)

CYP2C19 inhibitors inc INR (amiodarone, azole antifungals, metronidazole, TMP/SMX)

46
Q

Warfarin DDI: CAM / supplements

A

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
Q

Warfarin tablet colors:
Please Let Greg Brown Bring Peaches To Your Wedding

A

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
Q

Foods high in vitamin K

A

spinach
broccoli
Brussel sprouts
collard greens
kale
Others: turnip greens, green onion, asparagus, cabbage, cauliflower

NAPLEX Prep (40 decks)

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