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Anticoagulation Flashcards

1
Q

Heparin dosing: VTE prophy

A

5000 units SQ q8h (duh)

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2
Q

Heparin dosing: VTE treatment

A

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

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3
Q

Heparin dosing: ACS/STEMI treatment

A

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

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4
Q

What body weight should you use for heparin dosing?

A

TBW

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5
Q

Enoxaparin dosing: VTE prophy

A

30mg SQ q12h or 40mg SQ QD

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6
Q

Enoxaparin dosing: VTE prophy in CrCl <30

A

30mg SQ QD

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7
Q

Enoxaparin dosing: VTE, UA/NSTEMI treatment

A

1mg/kg SQ q12h
1.5mg/kg SQ QD in inpatient setting

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8
Q

Enoxaparin dosing: VTE, UA/NSTEMI treatment with CrCl <30

A

1mg/kg SQ QD

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9
Q

Enoxaparin dosing: STEMI treatment in patients <75 years of age

A

30mg IV bolus, then 1mg/kg SQ dose, then 1mg/kg SQ q12h dose

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10
Q

Enoxaparin dosing: STEMI treatment in patients <75 years of age with CrCl <30

A

30mg IV bolus, then 1mg/kg SQ dose, then 1mg/kg SQ QD dose

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11
Q

Enoxaparin dosing: STEMI treatment in patients ≥75 years of age

A

0.75mg/kg SQ q12h, NO BOLUS

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12
Q

Enoxaparin dosing: STEMI treatment in patients ≥75 years of age with CrCl <30

A

1mg/kg SQ QD

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13
Q

What body weight do you use with enoxaparin dosing?

A

TBW

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14
Q

Dalteparin dosing: VTE prophy

A

2500-5000 units

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15
Q

Dalteparin dosing: UA/NSTEMI treatment

A

120 units/kg SQ q12h, max: 10,000 units

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16
Q

Eliquis missed dose instructions

A

Take immediately on the same day, then resume BID dosing. The dose shouldn’t be doubled up

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17
Q

Eliquis dosing: nonvalvular Afib

A

5mg PO BID

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18
Q

Eliquis dosing: nonvalvular Afib renal dosing criteria

A

Decrease to 2.5mg BID if 2/3 criteria met:
Age >80
Weight <60kg
SCr >1.5

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19
Q

Eliquis dosing: DVT/PE treatment

A

10mg BID x7 days, then 5mg BID

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20
Q

Eliquis dosing: DVT/PE extended treatment

A

After >3 months of treatment: 2.5mg PO BID

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21
Q

Eliquis dosing: DVT prophy after knee/hip replacement

A

2.5mg PO BID for 12 days after knee replacement, 35 days after hip replacement

Give 12-24 hours after surgery

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22
Q

Xarelto missed dose instructions: 15mg PO BID

A

Take immediately to make sure you get 30mg/day
AKA: 2, 15mg tabs can be taken at once!

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23
Q

Xarelto missed dose instructions: 10, 15, or 20mg QD

A

Take immediately on same day; if not, just skip

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24
Q

What doses of Xarelto need to be taken with food?

A

Anything ≥15mg

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25
Q

Xarelto dosing: nonvalvular AF (stroke prophy), CrCl >50

A

20mg PO QD with dinner

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26
Q

Xarelto dosing: nonvalvular AF, CrCl 15-50

A

15mg PO QD with dinner

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27
Q

Xarelto dosing: nonvalvular AF, CrCl <15

A

Don’t use

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28
Q

Xarelto dosing: treatment of DVT/PE

A

15mg PO BID x21 days, then 20mg QD with food

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29
Q

Xarelto dosing: extended treatment of DVT/PE

A

After ≥3 months of treatment: 10mg PO QD

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30
Q

Xarelto dosing: DVT prophy after knee/hip replacement or acutely ill patients

A

10mg PO QD x12 days- knee replacement
10mg PO QD x35 days- hip replacement
10mg PO QD x31-39 days- acutely ill

Give first dose 6-10 hours after surgery
Avoid in CrCl <30

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31
Q

Xarelto dosing: reduction in risk of major CVD or CAD/PAD

A

2.5mg PO BID in combination with low-dose ASA
CrCl <15: avoid use

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32
Q

Edoxaban missed dose counseling

A

Take immediately on the same day; don’t double up

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33
Q

Edoxaban dosing: nonvalvular AF (stroke prophy), CrCl >95

A

Don’t use

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34
Q

Edoxaban dosing: nonvalvular AF (stroke prophy), CrCl 51-95

A

60mg QD

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35
Q

Edoxaban dosing: nonvalvular AF, CrCl 15-50

36
Q

Edoxaban dosing: nonvalvular AF, CrCl <15

A

Don’t use

37
Q

Edoxaban dosing: treatment of DVT/PE

A

60mg PO QD, start after 5-10 days of parenteral anticoagulation
CrCl 15-50, body weight is ≤60kg, or on certain P-gp inhibitors: 30mg PO QD
CrCl <15: don’t use

38
Q

Fondaparinux dosing: VTE prophy, ≥50kg

A

2.5mg SQ QD

39
Q

Fondaparinux dosing: VTE prophy, <50kg

40
Q

Fondaparinux dosing: VTE treatment, <50 kg

41
Q

Fondaparinux dosing: VTE treatment, 50-100kg

A

7.5mg SQ QD

42
Q

Fondaparinux dosing: VTE treatment, >100kg

A

10mg SQ QD

43
Q

Fondaparinux dosing: CrCl 30-50ml

A

Use caution

44
Q

Fondaparinux dosing: CrCl <30ml

45
Q

Fondaparinux BBW

A

neuraxial anesthesia

46
Q

Don’t give fondaparinux via what route of administration?

47
Q

Dabigatran missed dose counseling

A

Take immediately UNLESS it’s within 6 hours of the next dose, don’t double up

48
Q

Dabigatran dosing: nonvalvular AF

A

150mg PO BID

49
Q

Dabigatran dosing: nonvalvular AF, CrCl 15-30ml/min

A

75mg PO BID

50
Q

Dabigatran dosing: nonvalvular AF, CrCl <15

51
Q

Dabigatran dosing: treatment of DVT/PE and reduction in risk of recurrent DVT/PE

A

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

52
Q

Dabigatran dosing: prophy of DVT/PE after hip replacement surgery

A

110mg on day 1, then 220mg QD

53
Q

Dabigatran BBW

A

Patients receiving neuraxial anesthesia or undergoing spinal puncture are at risk of hematomas and subsequent paralysis

premature D/C increases risk of thrombotic events

54
Q

Dabigatran CIs

A

Active bleeding, mechanical heart valves

55
Q

Dabigatran storage

A

Store in original container at room temperature and discard 4 months after opening

56
Q

Argatroban HIT dosing

A

2mcg/kg/min, then titrate to target aPTT
Max: 10mcg/kg/min

57
Q

Argatroban/bivalirudin dosing: PCI

A

IV bolus followed by an infusion, all are weight-based
Used in patients at risk for HIT

58
Q

When to decrease argatroban dose

A

Hepatic impairment

59
Q

When to decrease bivalirudin dose

A

CrCl <30 ml/min

60
Q

Warfarin dosing: healthy outpatients

A

≤10mg daily for first 2 days, then adjust per INR

61
Q

Warfarin missed dose counseling

A

Take immediately on same day, don’t double up the dose the next day

62
Q

Warfarin dosing: elderly, malnourished, drugs that can increase warfarin levels, heart failure, high risk for bleeding

63
Q

Warfarin INR: when to use a goal of 2-3

A

most indications: VTE, AF, bioprosthetic mitral valve, mechanical aortic valve, antiphospholipid syndrome

64
Q

Warfarin INR: when to use a goal of 2.5-3.5

A

mechanical valves

65
Q

Presence of what alleles and polymorphism can increase bleeding risk while taking warfarin?

A

CYP2C9*2 or *3 alleles, VKORC1 polymorphism

66
Q

How soon should you stop warfarin in patients before they get surgery?

67
Q

What if the patient getting surgery is taking warfarin but they’re at high risk of a bleed?

A

Stop the warfarin, start them on enoxaparin or heparin

68
Q

If a patient HAS to take enoxaparin before surgery, when do you D/C it?

A

24 hours before

69
Q

If a patient HAS to take heparin before surgery, when do you D/C it?

A

4-6 hours before

70
Q

When do you restart warfarin after surgery?

A

12-24 hours after the procedure when there’s adequate hemostasis

71
Q

Duration of VTE treatment: known cause

72
Q

Duration of VTE treatment: unknown cause

A

could be indefinite, but definitely more than 3 months

73
Q

Meds to give patients with DVT without cancer

A

Dabigatran and the DOACs are preferred over warfarin for the firsts 3 months

74
Q

Meds to give patients with DVT AND cancer

A

DOACs are preferred over other PO meds and Lovenox

75
Q

Med to give patient who had an unprovoked DVT or PE who stopped anticoagulation

76
Q

Components of CHA2DS2VASc score

A

CHF
HTN
Age ≥75 years
Diabetes
Stroke
Vascular disease
Age 65-74
Female sex

77
Q

What does the CHA2DS2VASc score measure?

A

Patient’s stroke risk and whether they should be started on anticoagulation

78
Q

CHA2DS2VASc score needed to start anticoagulation

A

≥2 for males
≥3 for females

79
Q

HASBLED score components

A

HTN (SBP >160)
Abnormal liver or kidney function
Stroke history
Bleeding tendency/predisposition
Labile INR (on warfarin)
Elderly (>65 years old)
Drugs (ASA, NSAIDs, excess alcohol use)

80
Q

What does the HASBLED score measure?

A

Patient’s risk for a bleed

81
Q

Preferred anticoagulation in pregnancy

A

Enoxaparin

82
Q

Warfarin to DOAC: when to start Xarelto

A

When INR <3

83
Q

Warfarin to DOAC: when to start Savaysa

A

When INR <2.5

84
Q

Warfarin to DOAC: when to start Eliquis

A

When INR <2

85
Q

Warfarin to DOAC: when to start Pradaxa

A

When INR <2

86
Q

DOAC to warfarin (except for dabigatran): how to transition

A

Start parenteral anticoagulant and warfarin at next scheduled dose

87
Q

Pradaxa to warfarin transition

A

Start warfarin 1-3 days before stopping Pradaxa (determined by renal function- have to look at the package insert for more detail)

NAPLEX (18 decks)

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