Anticoagulation Flashcards
Aransesp
darbepoetin alfa
Darbepoetin alfa side effects
Arthralgia, HTN, MI, stroke
Praxbind
Idarucizumab
Savaysa
Edoxaban
Dabigatran administration
Swallow with a full glass of water
UFH Monitoring
Hematocrit, hemoglobin, aPTT, platelets
HIT treatment
Discontinue heparin, if on warfarin - disconitnue and give vitamin K, start anti-thrombin (argatroban, bivalirudin)
Elemental iron in ferrous sulfate, ferrous sulfate (dried), and ferrous fumarate
20%, 30%, 33%
Antidote for iron overdose
IV deferoxamine or PO deferasirox (dexrazoxane is for doxorubicin)
Enoxaparin renal dosing
CrCl < 30 – daily dosing
Which IV iron formulation has highest risk of anaphylaxis?
Iron dextran
When to use warfarin over DOACs
- troke prevention in Afib if there is moderate-to-severe stenosis or a mechanical heart valve
- VTE treatment if the patient has antiphospholipid syndrome or a mechanical heart valve
Which warfarin enantomer is more potent and which enzyme is responsible primarily for its metabolism?
S-warfarin, CYP2C9
Which drugs are inducers of warfarin metabolism?
DECREASE INR: carbamazepine, phenobarbital, phenytoin, rifampin, SJW
Which drugs are inhibitors of warfarin metabolism?
INCREASE INR: amiodarone, fluconazole, metronidazole, Bactrim
How to bridge warfarin with heparin for acute DVT/PE?
Start warfarin on same day as heparin and continue both for at least 5 days, discontinue heparin once INR has been > 2 for 24 hours (2 levels)
How often to check INR in stable patients
Usually 4 weeks but if consistently stable, 12 weeks
Warfarin Colors
Please Let Greg Brown Bring Peaches To Your Wedding - pink, lavendar, green, brown, blue, peach, teal, yellow, white - 1, 2, 2.5, 3, 4 , 5, 6, 7.5, 10
Main interactions with factor Xa inhibitors
CYP3A4 inducers
Apixiban dosing
5 mg BID (afib), 10 mg BID x7d then 5 mg BID (DVT treatment)
2.5 mg BID if Scr > 1.5, age > 80 or weight < 60 (need 2)
Rivaroxaban dosing
15 mg BID x21d then 20 mg daily (treatment)
Avoid use if CrCl < 30
Rivaroxaban administration
Take with food, DO double up on doses
Edoxaban dosing
Do not use if CrCl > 95
UFH Dosing
5000 units SQ Q8-12H (VTE ppx)
80 units/kg IV bolus + 18 units/kg/hr (VTE treatment)
60 units/kg IV bolus + 12 units/kg/hr (STEMI/NSTEMI)
LMWH Dosing
30 mg BID or 40 mg daily (VTE ppx)
1 mg/kg Q12H (NSTEMI)
30 mg IV bolus (STEMI, age < 75)
0.75 mg/kg Q12H (STEMI, age > 75)
Do daily dosing if CrCl < 30
UFH side effects
Bleeding, HIT, hyperkalemia
LMWH side effects
Bleeding, HIT, anemia
UFH monitoring
aPTT or anti-Xa 6 hr post infusion and Q6H after (goal 0.3-0.7)
LMWH monitoring
Anti-Xa 4 hours post dose (only if pregnant, obese, low weight, renal dysfunction)
Heparin reversal (and dosing)
Protamine
1 mg = 100 units UFH
1 mg = 1 mg LMWH
Dabigatran reversal
Idarucizumab (Praxbind)
Apixiaban/Rivaroxaban reversal
Andexanet alfa (Andexxa)
Warfarin reversal parameters
INR < 4.5: skip warfarin
INR 4.5-10: skip 1-2 doses of warfarin
INR > 10: PO vitamin K
Any serious bleeding regardless of INR: IV vitamin K + Kcentra
Warfarin bridging prior to surgery
Discontinue warfarin 5 days prior to surgery
Start heparin up until 24 hours prior (LMWH) or 4-6 hours prior (UFH) if high risk of thromboembolism
Restart warfarin 12-24 hours post-op
Duration of VTE treatment
Provoked: 3 months
Unprovoked: AT LEAST 3 months
(can add aspirin when d/c’ing in these patients)
Afib anticoagulation – undergoing cardioversion
Anticoagulation 3 weeks prior and 4 weeks aftter (if started > 48 hours prior or unknown duration)
Start anticoagulation upon presentation and continue after cardioversion for 4 weeks (if started < 48 hours prior)
CHADS-VASc
CHF-1
HTN-1
Age 75 or older-2
Diabetes-1
Stroke-2
Vascular disease-1
Age 65 -74-1
Sex (female): 1
Score of at least 2 (don’t consider sex)
HAS-BLED
HTN (SBP > 160)-1
Abnormal liver or kidney-1-2
Stroke-1
Bleeding tendency-1
Labile INR-1
Elderly (> 65)-1
Drugs (aspirin, NSAIDs)-1-2
Conversion from warfarin to anti-xa or dabigatran (INR cut offs)
READ
Rivaroxaban - INR < 3
Edoxaban - INR < 2.5
Apixaban - INR < 2
Dabigatran - INR < 2
PO iron administration
Take on an empty stomach, avoid H2RAs/PPIs
Iron recommendation for pregnant women
All should take 30 mg/day
What supplement helps iron absorption
Vitamin C (acidic environment)
IV iron dose need to replenish iron stores
1000 mg
IV iron appropriat for?
Hemodialysis, receiving ESAs, unable to tolerate PO, severe anemia (Hgb < 7), alternative to blood transfusion in those who can’t receive for religious reasons
What anemic deficiency leads to neurologic symtpoms
Vitamin B12
Pernicious anemia
Lifelong B12 replacement
Causes of B12/folate anemia
Alcoholism, poor nutrition, GI disorders, pregnancy, long-term use of metformin, PPIs/H2RAs
When to initiate ESA in anemia of CKD?
Hgb < 10
Which ESA has a longer half-life
Darbepoetin
Drugs to avoidf in G6PD deficiency
Dapsone, methylene blue, nitrofurantoin, primaquine, pegloticase, rasburicase, quinidine, quinine, sulfonamides
Sickle cell RBC turnover
10-20 days
Sickle cell - when to blood transfusion
Stroke, severe anemia, chest syndrome
Goal hemoglobin with blood transfusion in sickle cell and why
No higher than 10 - can cause iron overload (treat with iron antidote deferasirox or deferiprone)
Only cure for sickle cell
Bone marrow transplant
Vaccines for children with sickle cell
Hib, pneumococcal, meningococcal
Antibiotic prophylaxis in sickle cell
Birth to age 5: give penicillin (continue indefinitely if surgical removal of spleen or invasive pneumo infection despite antibiotics)
Hydroxyurea MOA
stimulates production of fetal hemoglobin
Indication for hydroxyurea
adults with 3 more more moderate-severe pain crises in 1 year
Warnings with hydroxyurea
Myelosuppression, hazardous, teratogenic
L-glutamine MOA
amino acid shown to reduce acute complications of sickle cell through oxidative stress
Voxelotor MOA
inhibits HgbS polymerization
Crizanlizumab MOA
inhibits adhesion of sickle RBCs to vessels
