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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
Q

What should you do if the patient has cancer and is needing anti-coagulation?>

A
  • WITH cancer: DOACs over other oral anti-coag and LMWH
  • WITHOUT cancer: Dabigatran and DOACs over Warfarin for first 3 months
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26
Q

What is INR and what does it mean when the valves are high or low?

A
  • INR: how long it takes for the blood to clot
  • HIGH INR = blood clots slower [thinner]
  • LOW INR = blood clots easier [thicker]
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27
Q

What are some of the drug interactions for Dabigatran

A
  • 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
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28
Q

What are some of the important drug interactions with the DOACs?

A
  • 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
Q

What are the contraindications and side effects on Enoxaparin?

A
  • Contraindications: Hx of HIT, Major Bleeding
  • SE: BLEEDING, anemia, injection site reactions, decreased platelets
30
Q

When looking at the use of Vitamin K for Overanticoagulation; what should you do when the INR is 4.5-10 without bleeding?

A
  • Vitamin K is NOT needed with no bleeding, so… Hold 1-2 doses of warfarin and monitor the INR
31
Q

What are some warning and side effects for UFH?

A
  • Warning: Fatal Medication Error [high bleed risk]
  • Side Effects: BLEEDING, thrombocytopenia, HIT, Hyperkalemia, osteoprosis
32
Q

What are some Key Counseling Points for Dabigatran>

A
  • 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
Q

What is the MOA for Unfractionated Heparin?

A
  • Binds to AT [Anti-thrombin] and Xa which prevents the formation of Fibrin
34
Q

What are some of the Key counseling points for ALL anti-coag drugs?

A
  • 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
Q

What are some Key counseling points for warfarin?

A
  • Take at the same time everyday
  • Tablet color??
  • INR monitoring is frequent
  • Consistant Vitamin K intake [those leafy greens]
36
Q

What are some things to monitor when taking UFH?

A
  • aPTT and anti-Xa Level; check every 6 hours until theraputic
  • aPTT range: 1.5 - 2.5
37
Q

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?

A
  • Reduce or skip the warfarin dose and monitor the INR
38
Q

What are all the approved medications for VTE Prophylaxis

A
  • UFH, LMWH, Rivaroxaban, Apixaban, Fondaparinux, and Dabigatran
39
Q

What is the CHADSVASc score?

A
  • Estimates stroke risk in a patient
40
Q

What are the antidotes that are used for warfarin?

A
  • Vitamin K or Phytonadione
  • 4 Factor Prothormbin Complex Concentrate
  • 3 Factor Prothormbin Complex Concentrate
  • Factor VIIa Recombinant
41
Q

What is the Diagnosis for a VTE [DVT or PE]?

A
  • DVT: Pain in the limbs & lower extremity swelling
  • PE: SOB & Chest Pain

DVTs can be diagnosed my an Ultrasound

42
Q

What are some Black Boxed Warnings and Contraindications for Dabigatran?

A
  • Black Boxed: increase Risk of Hematomas and paralysis for those getting neuraxial anesthesia
  • Contraindications: Avoid in those with Mechanical Prosthetic Heart Valves
43
Q

What is the main drug and MOA for Low Molecular Weight Heparin?

A
  • Enoxaparin (Lovenox)
  • Binds to AT and Xa to prevent Fibrin from forming
44
Q

What are the colors and strengths associated with the pills of Warfarin?

A
  • 1mg = Pink
  • 2mg = Lavender
  • 2.5mg = Green
  • 3mg = Brown
  • 4mg = Blue
  • 5mg = Peach
  • 6mg = Teal
  • 7.5mg = Yellow
  • 10mg = White

“Please Let Granny BROWN Bring PEACHes To Your Wedding

45
Q

What is the dosing for Fondaparinox for Prophoylaxis and Treatment of VTE?

A
  • 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
Q

What are the Warnings and contraindications for DOACs?

A
  • Contraindications: BLEEDING
  • Warnings: NOT TO USE in those with a prosthetic Heart Valve or Antiphospholipid syndrome
47
Q

What is the MOA of th Direct Thrombin Inhibitors?

A
  • Directly inhibit Thrombin (IIa) preventing the clot formation
48
Q

What is the MOA for Warfarin?

A
  • Competitively Inhibits VKORC1 [Vit K Epoxide Reductase] which will decrease the regeneration of Vit K = decrease in factors II, VII, IX, X
49
Q

When looking atthe use of Vitamin K for Overanticoagulation; what should you do when there is major bleeding?

A
  • Hold Warfarin & give Vitamin K 5 - 10mg by Slow IV injection and 4-PCC
50
Q

What is the antidote for Xa inhibitors and how is it dosed?

A
  • Andexanet Alfa [Andexxa]
  • Dosage is based on last dose and time

Low Dose = 400mg IV Bolus + 4mg/kg over 2 hours
High Dose = 800mg IV Bolus + 8mg/kg over 2 hours

51
Q

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?

Long Distance Travelers?

A
  • 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
Q

In 4 Factor Prothrombin Complex Concentrate, what are some of the importnat things found in it?

A
  • Contains factors II, VII, IX, X, Protein C & S
  • Should give with Vit K
53
Q

What is Heparin Induced Thrombocytopenia?

A
  • 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
Q

What is are the drugs and MOA for the Factor Xa Inhibitors?

A
  • Apixaban, Rivaroxaban, Edoxaban, Fondaparinox
  • MOA: Inhibit Xa and Anti-Thrombin [mostly Xa] decreasing the clot formation
55
Q

What are Anti-coag’s used for?

A
  • Acute Coronary Syndrome (ACS)
  • Stroke Prevention
  • Veinous Thromboembolism (VTE) Treatment/Prevention [which is DVT and/or PE
56
Q

What are some of the side effects and monitoring for Dabigatran>

A
  • Side Effects: Dyspepsia, Gastritis, BLEEDING [GI Bleeding]
  • Monitoring: Hgb, Hct, SCr
57
Q

What drug is considered the Vitamin K Antagonist and what is important to know about it?

A
  • Warfarin
  • Vit K is need for VII, II, IX, X; without Vit K in the liver = NO CLOTTING

CHECK INR –> can change based on Drugs and Vit K intake

58
Q

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

A
  • 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
Q

What are the Black Boxed Warnings for the DOACs

A
  • Increased risk of hematomas and paralysis in those getting Neuraxial anesthesia
60
Q

What are some things to monitor when taking Enoxaparin?

A
  • Platelets, Hgb, Hct, SCr
  • NO Anti-Xa monitoring [recommended in prenancy tho]
61
Q

When looking at the use of Vitamin K for Overanticoagulation; what should you do when the INR > 10 without bleeding?

A
  • Hold warfarin & give Vitamin K 2.5 - 5mg even if no bleeding; monitor the INR
62
Q

What are some of the drug interactions with Heparins.

A
  • Anything that increases the bleed risk [other anti-coags, antiplatelets, some herbals, NSAIDS, SSRIs, SNRIS, thrombolytics
63
Q

What is the Dosing for UFH for Prophylaxis of VTE, Treatment of VTE and Treatment of ACS/STEMI?

A
  • 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
Q

What are some important foods that help with Vitaman K levels?

A
  • Spinach [cooked]
  • Broccoli
  • Brussel Sprouts
  • Collard Greens
  • Kale
  • Teas
  • Asparagus
  • Cabbage
  • Canola Oil
  • Green Onion
65
Q

What are some of the drug interactions with Warfarin?

A
  • 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
Q

What are some of the contraindications and warnings for those that use Warfarin>

A
  • 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
Q

What is the antidote that is used for UFH/LMWH and how is it dosed?

A
  • 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

Could cause Hypotension, Bradycardia, Flushing, Anaphylaxis

68
Q

What are some things to Monitor when taking Warfarin?

A
  • 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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