Anticoagulation Flashcards by Kaitlyn Coronel

VTE: Risk Factors

-Age
-VTE hx
-Surgery
-Trauma
-Immobility
-Malignancy
-Pregnancy
-Hormone/contra
-Hypercoag state
-Obesity

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DVT: Signs/Sx

-Unilateral leg swelling (warm, tender, discolored)
-Pain when foot is flexed (+ Homan’s sign)
-Palpable cord in veins

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PE: Signs/Sx

-Dyspnea
-Tachypnea
-Chest pain, tightness
-Tachycardia
-Palpitations

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DVT: Diagnosis

-Compression US (doppler)
-Elevated D-dimer (over 240)
-Wells score of 2+

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PE: Diagnosis

-V/Q scan
-Elevated D-dimer (over 240)
-Pulmonary angiogram
-Simple Wells score of > 4

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General Approach: PE with cardiopulmonary compromise OR DVT with high risk of limb loss

= FIBRINOLYTIC therapy + UFH or LMWH

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General Approach: Active bleeding or CI to AC

Is VTE a lower extremity DVT?

-YES = place IVC filter, start AC when bleeding stops or CI resolves, then remove IVCF asap

-NO = decide if patient will be inpatient or outpatient and follow that tx

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General Approach: PE with poor prognosis or DVT unsuitable for outpt

Hospitalize

CrCl < 30
= UFH x5 days overlap with Warfarin and INR > 2

Normal CrCl
= Same ^
= or UFH transition to DOAC
= or any outpt tx (RALF DWEL)

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General Approach: Outpatient Choices

-Rivaroxaban
-Apixaban
-LMWH/Fonda x5d then Dabi/Edoxaban
-LMWH/Fonda x5d overlap with Warfarin and INR > 2
(RALF DEW)

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Risk Factors for Major Bleeding While Taking Anticoagulation Therapy

-High AC intensity
-Initiation of AC
-65+
-Concurrent ASA/AP
-NSAID
-GI bleeding
-Surgery/trauma
-Fall risk
-Alcohol use
-Renal failure

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Fibrinolytic Drugs:
-Alteplase (t-PA)
-Tenecteplase (TNK)
-Streptokinase
-Urokinase

For:
-Massive DVT at risk for gangrene (d/t occlusion)
-Hemo unstable PE patients (SBP < 90, shock)

Potential to dissolve not only pathologic thrombi but physiologically appropriate fibrin clots
-could lead to hemorrhage of varying severity

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Contraindications for Fibrinolytic Drug (TPA, TNK)

-Active bleeding, hemorrhage hx
-Ischemic stroke within 3 months
-Cancer/vascular lesion
-Aortic dissection
-Trauma/surgery (head/spine)
-Severe uncon HTN

BIH STACH

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Before fibrinolytic therapy begins, administer IV heparin in full therapeutic doses

Heparin

Use actual body wt

LD: 80 u/kg bolus (MAX: 10,000)

MD: 18 u/kg/hr (MAX: 2,150)

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Alteplase (TPA): Dosing

PE: 100 mg IV inf over 2 hrs x1

Cardiac arrest: 50 mg IV bolus x1

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Initial ACUTE Phase

-Unfractionated heparin (UFH, IV or SC)
-SC Low molecular weight heparin (LMWH)
-SC Fondaparinux
-Oral rivaroxaban or apixaban

FULAR

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Oral dabigatran and edoxaban require…

5-10 days of parenteral therapy first

Acute: Transition from parenteral therapy to orals

– Continue for at least 5 days and until warfarin is therapeutic (INR 2-3) for at least 24 hours… then continue on PO warfarin alone

– No overlap is necessary if switching to rapid acting DOAC (rivaroxaban or apixaban)

Heparin: Dosing + AEs

IV: 80 u/kg (max 10,000) followed by 18 u/k/hr (max rate 2,150 u/hr)

-goal aPTT 50-77 seconds
-goal anti-Xa 0.3-0.7 IU/mL

Preferred in RENAL impairment

AE: HHHHON
-Narrow therapeutic window
-Heparin induced thrombocytopenia
-Hemorrhage
-Hypersensitivity rxn
-Hyperkalemia
-Osteoporosis

LMWH: Enoxaparin Dosing

1 mg/kg SC BID or 1.5-2 mg/kg SC QD

LMWH: Dalteparin Dosing

Month 1
-200 IU/kg SC QD

Month 2-6
-150 IU/kg SC QD

(max 18k)

LMWH: Dalte/Enox Monitoring

Higher risk patients that may require monitoring:
– obese patients
– renal impairment (CrCl < 30)
– elderly and children
– cancer

CCEO 30

IF ABOVE THEN USE ANTI-FACTOR XA

Heparin Induced Thrombocytopenia

Platelet count drop of 50% from baseline
Venous or arterial thrombosis
Skin lesions at heparin injection sites
Acute systemic reactions that occur after a bolus of IV heparin

*Prompt DC of ALL heparin products

Alternatives in HIT

Stable
-Fondaparinux

ICU, dialysis, CrCl < 30
-Bivalirudin
-Argatroban

Fondaparinux: Dosing

< 50 kg: 5 mg SC daily

50-100 kg: 7.5 mg SC daily

> 100 kg: 10 mg SC daily

CI in CrCl < 30

Bivalirudin

-Alternative to heparin in HIT or CABG/angioplasty

Normal dose: 0.15 mg/kg/hr

Argatroban

Used as alternative to heparin in HIT

Normal dose: 2 mcg/kg/min IV

Dabigatran: DOAC

(dabi is 30 but acts 150, GRH she’s a B)

-ClCr > 30 after 5- 10 days of parenteral therapy:
= 150 mg PO BID

-ClCr ≤ 30 mL/min: NO

AE:
-Bleeding, GI distress, rash, hives

Rivaroxaban: DOAC

(BOB goes down the river at 15 15 x2 x21 20)

-ClCr ≥ 15: 15 mg PO BID x 21 days then 20 mg PO qPM

-ClCr < 15: CI

To reduce risk of recurrence:
-ClCr > 15: 10 mg PO daily after at least 6 mo

AE:
-Bleeding, back pain, osteoarthritis

Apixaban: DOAC

10 mg PO BID x 7 days, then 5 mg PO BID thereafter

Reduce recurrence:
2.5 mg PO BID after at least 6 months of standard dosing

AE: bleeding

Edoxaban: DOAC

ClCr > 50 and after 5-10 days of parenteral therapy:
-Weight > 60 kg: 60 mg PO daily

ClCr 15-50 or weight ≤ 60 kg or use PGP inh: 30 mg PO daily

ClCr < 15: CI

AE: bleeding

Pt Ed for DOACs

-Do not abruptly stop taking your blood thinner (risk of thrombotic events)
-Report any bleeding (unexpected/lasts long/uncontrolled)
-May have higher risk of bleeding if you take aspirin, NSAIDs, warfarin

*Rivaroxaban with evening meal
*Dabigatran: use within 4 mo of opening bottle, keep capsules in original bottle at RT

Warfarin: INR/Dosing

Goal INR: 2-3
*2.5-3.5 for high-risk mechanical prosthetic heart valves

Age < 70
-AA: 7.5
-CH: 5
-As: 2.5

Age 70+
-AA: 5
-CH: F 2.5, M 5
-As: 2.5

Warfarin: DDIs

Increase War Metabolism
-Carb, pheny/pheno, SJW, rifampin

Decrease War Metabolism
-Amio, azoles, bactrim, cimetidine

Warfarin: Toxicities

-Bleeding
-Birth defects
-Skin necrosis
-Purple toe syndrome

Pt Ed for Warfarin

-Never skip a dose or take a double dose
-INR is the blood test used to determine how thin your blood is, will get it checked regularly
-Too much = bleeding, too little = clots
-AE: bleeding, bruising
-If you sustain an injury or fall OR you hit your head at any time, seek medical attention
-Food can affect it (broccoli, kale, Brussel sprouts, spinach) = keep diet consistent
-Alcohol limit 1 d/d

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Anticoagulation Flashcards

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