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Anticoagulation Flashcards

Chapter 34 (2025)

1
Q

What is the HAS-BLED score?

A
  • Assesses the bleeding risk in patients that are needing anti-coag
  • Needing anti-coag is based on CHADSVASc [stroke] when compared to HAS-BLED [bleed]
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2
Q

What is the dosing for Riveroxaban for Nonvalvular AFib [Stroke Prevention] and Treatment of DVT/PE [VTE]?

A
  • Nonvalvular AFib [Stroke Prevention]: CrCl > 50 = 20mg PO QD; CrCl 15-50 = 15mg PO QD; CrCl < 15 = Avoid Use
  • Treatment of DVT/PE [VTE]: 15mg PO BID x 21d, then 20mg PO daily WITH FOOD [CrCl < 30 = NO]

Missed dose: If 15mg BID… take Immediatly to equal 30mg/day; if 10, 15, 20mg QD… take immediatly

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3
Q

What is cardioversion and what are the anticoagluation treatments if someone where to undergo one?

A
  • Cardioversion: trying to “reset” back to normal sinus rhythm
  • Afib > 48h: Anti-coag for 3w prior to and 4w after
  • Afib < 48h: Full anti-coag to start; cardioversion; then continue full anti-coag dose
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4
Q

What is the dosing for Enoxaparin for Prophyalxis of VTE, Treatment of VTE/UA/NSTEMI, and Treatment of STEMI?

A
  • Prophylaxis of VTE: 30mg SubQ q12h or 40mg SubQ qd [CrCl < 30 = 30mg SubQ qd]
  • Treatment of VTE/UA/NSTEMI: 1mg/kg SubQ q12h or 1.5mg/kg SubQ daily [inpatient only VTE] [CrCl < 30 = 1mg/kg SubQ qd]
  • Treatment of STEMI: 30mg IV bolus + 1mg/kg SubQ, followed by 1mg/kg SubQ q12h [CrCl < 30 = 30mg IV bolus = 30mg IV bolus + 1mg/kg SubQ, followed by 1mg/kg SubQ qd]
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5
Q

What are the Black Box Warnings for Enoxaparin?

A
  • Those getting neuraxial anesthesia or spinal puncture are at risk of Hematomas and Subsequent Paralysis
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6
Q

When HIT occurs, what are some things that we need to do?

A
  • STOP all heparin/LMWH
  • If on Warfarin; D/C and start Vit K [wait until platelets are < 150,000 before starting]
  • Can give Argatorban [if Cardiac Srugery or PCI = Bivalirudin]
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7
Q

What are the Injectable Direct Thormbin Inhibitors and what are important to know about them?

A
  • Argatroban and Bivalirudin
  • Argatroban: used for those that have HIT or are undergoing PCI with high risk for HIT
  • Bivalirudin: Used for those that are undergoing PCI with high risk of HIT
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8
Q

What drugs are those that inhibit Xa and AT and what are some important things to note about them?

A
  • Xa and AT: Heparin [AT>Xa] and DOACs [Xa]
  • AT [Anti-Thrombin] is the bodeis natural Anticoagulant which inhibits IIa [Thrombin] and Xa

Heparins and cause HIT

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9
Q

What are some key counseling points for Enoxaparin?

A
  • Inject in right or left side of abdomin at least 2 inches away form belly button
  • Pull off cap straight; DO NOT rid bubbles [unless doctor said too]; Hold syringe like a pencil & pinch the skin; Insert at straight up/down & press the plunger; Remove straight out
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10
Q

When using the CHADSVASc Scoring system, what are the recommendations from the score?

A
  • 0 [Males] = NO Anti-coag
  • 1 [Female] = NO Anti-coag
  • 1 [Male] = Consider oral anti-coag
  • 2 [Female] = Consider oral anti-coag
  • >2 [Male] = Oral anti-coag; DOAC preferred
  • >3 [Females] = Oral anti-coag; DOAC preferred
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11
Q

What is the way that we score someone using CHADSVASc?

A
  • C: CHF = 1
  • H: HTN = 1
  • A: Age > 75 = 2
  • D: Diabetes = 1
  • S: Stroke Hx = 2
  • V: Vascular Disease = 1
  • A: Age 65-74 = 1
  • Sc: Female = 1
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12
Q

What is the antidote for dabigatran and how is it dosed?

A
  • Idarucizumab
  • 5g IV [as 2 separte 2.5g doses 15 mins apart]
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13
Q

What is the dosing for Warfarin

A
  • Healthy Outpatients: < 10mg PO QD
  • Elderly/Malnurished: < 5mg PO QD

< 5mg PO QD falso for those that have other drugs that increase warfarin levels, have liver disease, Heart Failure or increase bleed risk

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14
Q

What is important to know about the dosing for edoxaban?

CrCl?

A
  • CrCl > 95 = DO NOT USE
  • CrCl 51-95 = 60mg PO daily
  • CrCl 15-50 = 30mg PO Daily
  • CrCl < 15 = DO NOT USE
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15
Q

When should Injectable or Oral anti-coag drugs be used?

A
  • Injectable: VTE [Treatment/Prevention] and ACS
  • Oral: VTE [Treatment/Prevention] and Stroke Prevention [Those with AFib]
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16
Q

Out of the two active enantiomers, which is that more potent one?

A
  • S-Warfarin is more potent than R-Warfarin
  • S-Warfarin is 2C9
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17
Q

What is the Oral direct thormbin inhibitor that is used and what is the Dosing for it?

Nonvalvular AFIb and Treatment of DVT/PE

A
  • Dabigatran (Pardaxa)
  • Nonvalvular AFib: 150mg PO BID [CrCl 15-30 = 75mg PO BID & CrCl < 15 = AVOID]
  • Treatment of DVT/PE: 150mg PO BID; start after 5-10 days of parenteral anticoagulation
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18
Q

What are some Key Counseling Points for Rivaroxaban?

A
  • if AFib: QD with evening meal
  • if VTE: QD or BID with food at the same time everyday
  • Missed dose: if BID; take 2 doses at the same time
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19
Q

What is the dosing for Vitamin K used as an antidote for Warfarin?

A
  • 1-10mg PO/IV

If given IV, the rate CANNOT exceed 1mg/min or phebitis happens

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20
Q

For warfarin reversal, what are some of the important things to note when it come down to oral, SubQ, IM, and IV Vitamin K?

A
  • Oral: should give 2.5-5mg for those WITHOUT bleeding
  • SubQ: AVOID because of slow onset and repsonse
  • IM: AVOID because fo hematoma risk
  • IV: for SERIOUS bleed [could cause anaphylaxis; needs slow infusion]
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21
Q

How long should a VTE be treated for and can that be extended? If so, how?

A
  • VTE by surgery or reverible risk factor = treat for 3 Months; can extend IF the patient is at a low-moderate bleed risk
  • Extending therapy should use reduced doses of apixban or rivaroxaban
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22
Q

What is the way that we score someone usign HAS-BLED?

A
  • H: HTN = 1
  • A: Abnormal Liver or Kidney function = 1-2
  • S: Stroke Hx = 1
  • B: Bleeding Hx = 1
  • L: INR [if on warfarin] =1
  • E: Elderly [> 65yo] = 1
  • D: Drugs [Aspirin, NSAIDS…] = 1-2
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23
Q

In 3 Factor Prothrombin Complex Concentrate, what are some of the important things that are found in it?

A
  • Contains factors II, IX, X
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24
Q

For patinets that have a Mechanical Heart Valve, what medication is recommended for them for their AFib?

These patients are at the highest risk for stroke

A
  • Warfarin not DOACs or Direct Thrombin Inhibitors
  • Majortity fo people that have AFib do not have Mechanical Heart Valves
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25
What should you do if the patient has **cancer** and is needing **anti-coagulation**?>
- WITH cancer: DOACs over other oral anti-coag and LMWH - WITHOUT cancer: Dabigatran and DOACs over Warfarin for first 3 months
26
What is **INR** and what does it mean when the valves are **high or low**?
- INR: how long it takes for the blood to clot - **HIGH** INR = blood clots slower [thinner] - **LOW** INR = blood clots easier [thicker]
27
What are some of the **drug interactions** for **Dabigatran**
- Avoid with Rifampin or any P-gp inhibitor [CrCl < 50] - Reduce dose to 75mg PO BID IF CrCl 30-50 AND using Drondarone or ketoconazole - Cobicistat can increase exposure
28
What are some of the important **drug interactions** with the **DOACs**?
- Monitor with those that have additive bleeding effects [NSIADS, Antiplatelets, SSRIs, SNRIs, etc] - **Apixaban**: major 3A4 & P-gp substrate - **Rivaroxaban**: major 3A4 & P-gp substrate
29
What are the **contraindications and side effects** on **Enoxaparin**?
- Contraindications: Hx of HIT, Major Bleeding - SE: BLEEDING, anemia, injection site reactions, decreased platelets
30
When looking at the **use of Vitamin K for Overanticoagulation**; what should you do when the **INR is 4.5-10 without bleeding**?
- Vitamin K is **NOT** needed with no bleeding, so... Hold 1-2 doses of warfarin and monitor the INR
31
What are some **warning and side effects** for **UFH**?
- Warning: Fatal Medication Error [high bleed risk] - Side Effects: BLEEDING, thrombocytopenia, HIT, Hyperkalemia, osteoprosis
32
What are some **Key Counseling Points** for **Dabigatran**>
- Take with a full glass of water - **Dyspepsia** - Once bottle is open, it is only good for 4 months; DO NOT put in pill box - Missed dose: next dose in 6 hour? skip dose
33
What is the **MOA** for **Unfractionated Heparin**?
- Binds to **AT** [Anti-thrombin] and **Xa** which prevents the formation of Fibrin
34
What are some of the **Key counseling points** for **ALL** anti-coag drugs?
- Tell your doctor or dentist you are on anti-coag BEFORE surgery - Tell doctor if you fall - AVOID alcohol - Missed Dose: take ASAP on same day; DO NOT double up
35
What are some **Key counseling points** for **warfarin**?
- Take at the same time everyday - Tablet color?? - INR monitoring is frequent - Consistant Vitamin K intake [those leafy greens]
36
What are some things to **monitor** when taking **UFH**?
- aPTT and anti-Xa Level; check every 6 hours until theraputic - **aPTT range**: 1.5 - 2.5
37
When looking at the **use of Vitamin K for Overanticoagulation**; what should you do when the **INR is above therapeutic range BUT < 4.5 without bleeding**?
- Reduce or skip the warfarin dose and monitor the INR
38
What are all the **approved** medications for **VTE Prophylaxis**
- UFH, LMWH, Rivaroxaban, Apixaban, Fondaparinux, and Dabigatran
39
What is the **CHADSVASc** score?
- Estimates stroke risk in a patient
40
What are the **antidotes** that are used for **warfarin**?
- Vitamin K or Phytonadione - 4 Factor Prothormbin Complex Concentrate - 3 Factor Prothormbin Complex Concentrate - Factor VIIa Recombinant
41
What is the **Diagnosis** for a **VTE** [DVT or PE]?
- DVT: **Pain** in the **limbs & lower extremity swelling** - PE: **SOB & Chest Pain** ## Footnote DVTs can be diagnosed my an **Ultrasound**
42
What are some **Black Boxed Warnings and Contraindications** for **Dabigatran**?
- Black Boxed: increase **Risk of Hematomas and paralysis** for those getting **neuraxial anesthesia** - Contraindications: Avoid in those with **Mechanical Prosthetic Heart Valves**
43
What is the **main drug** and **MOA** for **Low Molecular Weight Heparin**?
- **Enoxaparin (Lovenox)** - Binds to **AT** and **Xa** to prevent Fibrin from forming
44
What are the **colors** and **strengths** associated with the pills of Warfarin?
- 1mg = Pink - 2mg = Lavender - 2.5mg = Green - 3mg = Brown - 4mg = Blue - 5mg = Peach - 6mg = Teal - 7.5mg = Yellow - 10mg = White ## Footnote "**P**lease **L**et **G**ranny **BROWN** **B**ring **PEACH**es **T**o **Y**our **W**edding
45
What is the **dosing** for **Fondaparinox** for **Prophoylaxis and Treatment of VTE**?
- Prophylaxis of VTE: **> 50kg = 2.5mg SubQ Daily** & **< 50kg = Contraindicated** - Treatment of VTE: **< 50kg = 5mg SubQ Daily**,**50-100kg = 7.5mg SubQ Daily** & **> 100kg = 10mg SubQ Daily**
46
What are the **Warnings and contraindications** for **DOACs**?
- Contraindications: **BLEEDING** - Warnings: **NOT TO USE in those with a prosthetic Heart Valve or Antiphospholipid syndrome**
47
What is the **MOA** of th **Direct Thrombin Inhibitors**?
- Directly inhibit **Thrombin** (IIa) preventing the clot formation
48
What is the **MOA** for **Warfarin**?
- Competitively Inhibits **VKORC1 [Vit K Epoxide Reductase]** which will **decrease** the regeneration of Vit K = **decrease** in factors **II, VII, IX, X**
49
When looking atthe **use of Vitamin K for Overanticoagulation**; what should you do when there is **major bleeding**?
- Hold Warfarin & give Vitamin K **5 - 10mg** by **Slow IV injection and 4-PCC**
50
What is the **antidote** for **Xa inhibitors** and how is it dosed?
- **Andexanet Alfa [Andexxa]** - Dosage is based on last dose and time ## Footnote Low Dose = 400mg IV Bolus + 4mg/kg over 2 hours High Dose = 800mg IV Bolus + 8mg/kg over 2 hours
51
If a patient is **contraindicated** for anti-coag or have **high bleeding risk**; what are some other alternatives that can be used fro **VTE prophylaxis**? ## Footnote Long Distance Travelers?
- Compression Devices or Stockings - Long-Distance Travelers: trying to get up an walk, calf exercises, stockings [15-30mmHg pressure] - **NO** Aspirin or Anti-coags
52
In **4 Factor Prothrombin Complex Concentrate**, what are some of the importnat things found in it?
- Contains factors **II, VII, IX, X, Protein C & S** - Should give with Vit K
53
What is **Heparin Induced Thrombocytopenia**?
- Immune mediated **IgG Drug reaction** that forms antibodies **against** heparin/PF4; this then makes a complex that binds to platelets to **activate** them making a **Prothrombic state** | **Unpxlained drop in platelet count [>50% from baseline]**
54
What is are the **drugs** and **MOA** for the **Factor Xa Inhibitors**?
- **Apixaban, Rivaroxaban, Edoxaban, Fondaparinox** - MOA: Inhibit Xa and Anti-Thrombin [mostly Xa] decreasing the clot formation
55
What are Anti-coag's used for?
- Acute Coronary Syndrome (ACS) - Stroke Prevention - Veinous Thromboembolism (VTE) Treatment/Prevention [which is DVT and/or PE
56
What are some of the **side effects and monitoring** for **Dabigatran**>
- Side Effects: **Dyspepsia**, Gastritis, BLEEDING [GI Bleeding] - Monitoring: Hgb, Hct, SCr
57
What drug is considered the **Vitamin K Antagonist** and what is important to know about it?
- **Warfarin** - Vit K is need for **VII, II, IX, X**; without Vit K in the liver = NO CLOTTING ## Footnote **CHECK INR** --> can change based on Drugs and Vit K intake
58
What is the **dosing** for **Apixaban** for **Nonvalvular AFib [Stroke Prevention], and Treatment of DVT/PE [VTE]**?
- Nonvalvular AFib [Stroke Prevention]: **5mg PO BID** - Treatment of DVT/PE [VTE]: **10mg PO BID x 7d, then 5mg PO BID** | Can be used for Knee/Hip Replacement DVT Prophylaxis; 2.5mg PO BID
59
What are the **Black Boxed Warnings** for the **DOACs**
- Increased **risk of hematomas and paralysis** in those getting **Neuraxial anesthesia**
60
What are some things to **monitor** when taking **Enoxaparin**?
- Platelets, Hgb, Hct, SCr - NO Anti-Xa monitoring [recommended in prenancy tho]
61
When looking at the **use of Vitamin K for Overanticoagulation**; what should you do when the **INR > 10 without bleeding**?
- Hold warfarin & give Vitamin K **2.5 - 5mg** even if no bleeding; monitor the INR
62
What are some of the drug interactions with Heparins.
- Anything that **increases the bleed risk** [other anti-coags, antiplatelets, some herbals, **NSAIDS, SSRIs, SNRIS,** thrombolytics
63
What is the **Dosing** for **UFH** for **Prophylaxis of VTE, Treatment of VTE and Treatment of ACS/STEMI**?
- Prophylaxis of VTE: **5,000 units SubQ q8-12h** - Treatment of VTE: **80 units/kg IV Bolus; 18 units/kg/hr infusion** - Treatment of ACS/STEMI: **60 units/kg IV Bolus; infuse 12 units/kg/hr**
64
What are some important **foods** that help with **Vitaman K** levels?
- Spinach [cooked] - Broccoli - Brussel Sprouts - Collard Greens - Kale - Teas - Asparagus - Cabbage - Canola Oil - Green Onion
65
What are some of the **drug interactions** with **Warfarin**?
- 2C9 inducers = increase INR [Carbamazepine, Phenobarbital, Phenytoin, St. Johns, Rifampin...] - 2C9 inhibitors = decrease INR [Amiodarone, Azoles, Capecitabine, Tamoxifin, Tigecycline, SMX/TMP...] - Alcohol and pain relivers can increase INR
66
What are some of the **contraindications** and **warnings** for those that use **Warfarin**>
- Contraindications: Pregnancy [unless with Mechanical Heart Valve] - Warnings: Tissue Necorosis/Gangrene., HIT, Purple Toe Sydrome (Very Rare), a 2C9 * 2 or * 3 Allele and/or polymorphism with VKORC1 = Increased bleeding
67
What is the **antidote** that is used for **UFH/LMWH** and how is it dosed?
- **Protamine**: combines with heparin to make a salt that stops the activity - UFH: 1mg Protamine per ~100 units of UFH [MAX: 50mg] - LMWH: 1mg Protamine per 1mg of Enoxaparin ## Footnote Could cause **Hypotension, Bradycardia, Flushing, Anaphylaxis**
68
What are some things to **Monitor** when taking **Warfarin**?
- Goal **INR of 2-3** of MOST people - Goal **INR of 2.5-3.5** for those with **Mechanical Heart Valves**

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