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BCPS > Anticoagulation > Flashcards

Anticoagulation Flashcards

1
Q

HAS-BLED

A

Hypertension (SBP >160)
Abnormal renal or hepatic function
Stroke history
Bleeding tendency or predisposition
Labile INR
Elderly (>65)
Drug or alcohol excess

Renal = chronic dialysis, renal transplant, SCr >= 2.26

Hepatic = Chronic hepatic disease, bilirubin >2x ULN, AST/ALT/ALP >3x ULN

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2
Q

Initiate warfarin 2-3mg in these groups

A

-Advanced age
-Low body weight (<45kg)
-Drug interactions
-Malnutrition
-Heart failure
-Hyperthyroid
-Low albumin, liver disease
-Ethnic groups (Asian)

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3
Q

Ideal Time in Therapeutic Range (TTR)

A

65-70%

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4
Q

S warfarin metabolism, common DI

A

CYP2C9 > CYP3A4

metronidazole, bactrim, fluconazole, isoniazid, fluoxetine, sertraline, amiodarone

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5
Q

R warfarin metabolism, common DI

A

CYP1A2, CYP3A4 > CYP2C19

clarithromycin/erythromycin, azoles, fluoxetine, amiodarone, cyclosporine, sertraline, grapefruit juice, FQs, PIs, diltiazem/verapamil, isoniazid, metronidazole

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6
Q

Dabigatran dosing, adjustment AFIB

A

Standard: 150mg BID

CrCl 15-30 ml/min: adjust to 75mg BID
CrCl 30-50 ml/min IN combo with ketoconazole or dronaderone: adjust to 75mg BID

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7
Q

Avoid dabigatran

A

CrCl <15 ml/min

Dialysis

CrCl 15-30 ml/min IN COMBO with verapamil, ketoconazole, dronedarone, clarithromycin

P-gp inducers (rifampin)

Chemo agents

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8
Q

Chemo agents that interact with all DOACs

A

Vinblastine, doxorubicin, imatinib, crizotinib, vandetanib, sunitinib, abiraterone, enzalutamide

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9
Q

Dabigatran metabolism

A

Renal, interactions occur w/ P-gp

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10
Q

Rivaroxaban dosing, adjustment AFIB

A

Standard: 20mg daily with food

CrCl 15-50 ml/min or dialysis: adjust to 15mg daily with food

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11
Q

Avoid rivaroxaban

A

Strong CYP3A4 and P-gp inducers or inhibitors

Chemo agents

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12
Q

Apixaban dosing, adjustments AFIB

A

Standard: 5mg BID

Adjust to 2.5mg BID:
If 2/3 criteria met (>= 80 y/o, weight <=60kg, SCr >= 1.5),
Use with strong CYP3A4 and P-gp inhibitors
Dialysis

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13
Q

Avoid apixaban

A

Strong CYP3A4 and P-gp inducers

Strong CYP3A4 and P-gp inhibitors (dose reduce or avoid if already on 2.5mg BID)

Chemo

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14
Q

Edoxaban dosing, adjustment AFIB

A

Standard: 60mg daily

CrCl 15-50 ml/min: adjust to 30mg daily

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15
Q

Avoid edoxaban

A

CrCl > 95 ml/min

CrCl < 15 ml/min

Dialysis

P-gp inducers

Chemo

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16
Q

Dabigatran to Warfarin conversion

A

CrCl >= 50 = initiate warfarin 3 days before discontinuing

CrCl 31-50 = initiate warfarin 2 days before discontinuing

CrCl 15-30 = initiate warfarin 1 day before discontinuing

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17
Q

Warfarin to Dabigatran

A

D/C warfarin, initiate dabigatran when INR <2.0

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18
Q

Dabigatran to Parenteral Anticoagulant

A

Wait 12 hr (CrCl > 30) or 24 hr (CrCl <30) after dabigatran to initiate parenteral

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19
Q

Parenteral Anticoagulant to Dabigatran

A

Initiate dabigatran 0-2 hours before next dose of parenteral dose due OR when UFH is discontinued

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20
Q

Rivaroxaban or Apixaban to Warfarin

A

D/C rivaroxaban. Start parenteral anticoagulant and warfarin as bridge

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21
Q

Warfarin to Rivaroxaban

A

D/C warfarin, start rivaroxaban when INR <3.0

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22
Q

Parenteral Anticoagulant to Rivaroxaban

A

Initiate rivaroxaban 0-2 hours before next scheduled administration

If on UFH, D/C heparin and start rivaroxaban at the same time

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23
Q

Warfarin to Apixaban

A

D/C warfarin and start apixaban when INR <2.0

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24
Q

Parenteral Anticoagulant to Apixaban

A

D/C anticoagulant and start apixaban at usual time of next dose

If on UFH infusion, DC infusion and start apixaban at same time

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25
Q

Edoxaban to Warfarin

A

If on edoxaban 60mg: reduce to 30mg and start warfarin at the same time. Once daily INR >=2.0, d/c edoxaban

If on edoxaban 30mg: reduce to 15mg and follow same as above

OR

D/C edoxaban and bridge warfarin with parenteral anticoag

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26
Q

Warfarin to Edoxaban

A

D/C warfarin and start edoxaban when INR <= 2.5

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27
Q

Parenteral Anticoagulant to Edoxaban

A

D/C anticoagulatn and start edoxaban at next scheduled time

If UFH, d/c infusion and start edoxaban 4 hours later

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28
Q

Trial results for DOAC vs Warfarin in AFIB

A

-Noninferior for stroke/stroke embolism

-ALL DOACS significantly lower rate of hemorrhagic stroke

-Dabigatran only DOAC w/ sig reduction of ischemic stroke

-Apixaban/edoxaban had sig reduction in major bleeding

-Apixaban only agent to show sig reduction in mortality compared to warfarin

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29
Q

Avoid/Caution DOACs in AFIB

A

Pregnancy
Breastfeeding
Severe hepatic dysfunction (Child-Pugh B or C)
Antiphospholipid syndrome
Bariatric surgery (Variable PKs)

Caution in obesity (BMI >40) or low body weight

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30
Q

Surgical Aortic Bioprosthetic Valve anticoag

A

Lifelong aspirin 81mg

Warfarin 2.0-3.0 if low bleed risk for 3-6 months

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31
Q

Transcatheter Aortic Valve implantation anticoag

A

Lifelong aspirin 81mg

Low risk of bleed: aspirin + clopidogrel x3-6 months
OR
Warfarin 2.0-3.0 x3-6 months

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32
Q

Mitral bioprosthetic valve anticoag

A

Lifelong aspirin 81mg

Low risk of bleed: warfarin 2.0-3.0 x3-6 months

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33
Q

Bioprosthetic valve placement AND AFIB anticoag

A

-Afib onset > 3 months after valve = DOAC

-Afib onset <3 moths after valve = warfarin

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34
Q

Valve replacements when INR 2.5-3.5 recommended

A

-Aortic mechanical valve with risk factors for thromboembolism, older generation valve

-On-X aortic valve with no risks for TE (for 3 months, then reduce INR to 1.5-2.0 w/ aspirin)

-Mitral mechanical valve

-Aortic & mitral heart valve

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35
Q

Mechanical heart valve bridging with surgeries

A

-No interruption in therapy needed for minor procedure (dental, cataract)

-Interrupt w/o bridge in invasive procedure w/ mechanical aortic valve & no risk for TE

-Interrupt w/ bridge if invasive procedure w/ mechanical aortic valve w/ risk factor or mechanical mitral valve

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36
Q

Enoxaparin VTE ppx for orthopedic surgeries

A

KNEE: 30mg q12H initiated 12-24 hours after surgery

HIP: 30mg SC q12H initiated 12-24 hours after surgery OR 40mg SC q24H initiated 12 (+-3) hours before surgery

HIP FRACTURE: 30mg SC q12H initiated 12-24 hours after surgery OR 40mg SC q24H initiated 12 (+-3) hrs before surgery

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37
Q

Dalteparin VTE ppx for orthopedic surgeries

A

KNEE: 2500 units SC initiated 6-8 hours after surgery, then 5000 units SC q24h

HIP: 2500 units SC initiated 4-8 hours after surgery, then 5000 units SC q24H OR 5000 units SC q24h initiated evening before surgery

HIP FRACTURE: insufficient evidence

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38
Q

Fondaparinux VTE ppx for orthopedic surgeries

A

KNEE, HIP, AND HIP FRACTURE
2.5mg SC q24h initiated 6-8 hours after surgery

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39
Q

Warfarn VTE ppx for orthopedic surgeries

A

KNEE, HIP, AND HIP FRACTURE
Initiate preop or evening of surgery day, INR goal 2.0-3.0

40
Q

Dabigatran VTE ppx for orthopedic surgeries

A

KNEE, HIP
110mg initiated 1-4 hours after surgery, then 220mg daily (PO)

HIP FRACTURE: insufficient evidence

41
Q

Rivaroxaban VTE ppx for orthopedic surgeries

A

KNEE, HIP
10mg daily initiated 6-10 hours after surgery

HIP FRACTURE: insufficient evidence

42
Q

Apixaban VTE ppx for orthopedic surgeries

A

KNEE, HIP
2.5mg PO BID initiated 12-24 hours after surgery

HIP FRACTURE: insufficient evidence

43
Q

VTE ppx after orthopedic surgery duration

A

10-14 days
Hip, fracture - up to 35 days

44
Q

Caprini Scale

A

Scale for non-ortho, abdominal pelvic surgery VTE ppx need

Risk of >=3 = pharmacologic vte ppx if avg bleed risk

Risk >= 5 = pharmacologic and mechanical VTE ppx

45
Q

Anticoagulants for general surgery vte ppx

A

LMWH > LDUH
If unavailable, aspirin 160mg or fondaparinux

46
Q

Bariatric surgery VTE ppx dosing

A

Higher than all others

LDUH: 5000unit SC q8h
Enoxaparin: 40mg q12h
Dalteparin: 7500 units SC q24h
Fondaparinux: 5mg SC q24h

47
Q

General surgery VTE ppx dosing (general, neuro, vascular, gyno, urologic, thoracic, CABG)

A

LDUH: 5000 units q8-12h (q8h necessary for neuro)

Enoxaparin: 40mg SC q24H

Dalteparin: 5000 units SC q24h (not used after neuro)

Fondaparinux: 2.5mg SC q24H (not used after neuro, CABG)

48
Q

PADUA Prediction Score Factors

A

Active cancer (3)
Previous VTE (3)
Reduced mobility (3)
Known thromboembolic condition (3)
Recent (<1mo) trauma/surgery (2)
>= 70 y/o (1)
Cardiac/respiratory failure (1)
Acute MI or ischemic stroke (1)
Acute infection and/or rheumo disorder (1)
BMI >= 30 (1)
Active hormonal treatment (1)

49
Q

PADUA >= 4

A

Low bleed risk: VTE ppx with LDUH, LMWH, fondaparinux (alt: low-dose rivaroxaban)

High bleed risk: mechanical ppx

50
Q

VTE ppx dosing in non-surgical, noncritically ill hospitalized pts

A

LDUH: 5000 untis q8-12h

Enoxaparin: 40mg SC daily

Dalteparin: 5000 units SC daily

Fondaparinux: 2.5mg SC daily

Rivaroxaban: 10mg daily

51
Q

Extended prophylaxis after hospitalization

A

Rivaroxaban 10mg daily for 35 days, including time in hospital if >=75, prolonged immobilization, cancer hx, VTE hx, HF, thrombophilia, active infectious disease, BMI >=35

*enoxaparin had higher bleed events

52
Q

VTE ppx for Trauma meds & doses

A

Dalteparin 5000 units q24 or enoxaparin 30mg q12H

Can initiate within 24-36 hours

If TBI, wait 72 hours

NOT LDUH OR FONDAPARINUX

53
Q

VTE ppx for Acute Spinal Cord injury meds & doses

A

LDUH 5000 units q8h

Enoxaparin 30mg q12h or 40mg q24h

Can initiate within 48-72 hours

NOT FONDAPARINUX

54
Q

VTE ppx for burns meds & doses

A

LDUH 5000 unit q8-12h

Enoxaparin 40mg daily or dalteparin 5000 SC q24h

NOT FONDAPARINUX

55
Q

General critical care VTE ppx meds & doses

A

LDUH 5000 q8-12h

Dalteparin 5000 q24h
Enoxaparin 30mg q12h or 40mg q24h

If HIT only, fondaparinux 2.5mg daily

56
Q

VTE ppx in pregnancy

A

LMWH or LDUH

Warfarin = teratogenic in first trimester
DOACs = no role

57
Q

VTE ppx in obesity

A

BMI >40 or >120kg reasonable to use:

Enoxaparin 40mg BID
Enoxaparin 0.5mg/kg BID
Dalteparin 7500 units daily
Fondaparinux 5mg daily
LDUH 7500 q8h

58
Q

VTE ppx duration postop for GI/GU/gyno cancer

A

up to 28 days

59
Q

VTE ppx duration in general surgery & pts with prior VTE

A

Duration of hospital stay if no prior VTE

up to 28 days if prior VTE

60
Q

VTE ppx duration in patients with major trauma

A

Up to 8 weeks if impaired immobility in rehab.

Otherwise, duration of hospital stay

61
Q

VTE ppx duration in spinal cord injury

A

Incomplete injury: hospital discharge

Uncomplicated complete motor injury: 8 weeks

Rehab if complete motor injury: 12 weeks or until discharge

62
Q

Homan sign

A

Pain in back of knee with dorsiflexon of foot – sign of DVT

63
Q

Wells Model for DVT Scores

A

0 = low risk (3%)
1-2 = moderate risk (17%)
>=3 = high risk

64
Q

Massive PE

A

Hemodynamic instability
SBP < 90
Cardiogenic shock

65
Q

Submassive PE

A

Normal SBP
Right ventricular dysfunction
Positive biomarkers

66
Q

Nonmassive PE

A

Hemodynamically stable

67
Q

Wells Model for PE Scores

A

0-1 = low risk (3-10%)
2-6 = moderate risk (15-35%)
>= 7 = high risk

68
Q

Dabigatran and Edoxaban bridge therapy for VTE

A

Injectable anticoagulant for 5 days, then switch to dabigatran or edoxaban

69
Q

UFH dosing VTE

A

-80 units/kg bolus (max 10,000 units), then 18 units/kg/hr (max 2,000 units/hr)

70
Q

Dalteparin dosing VTE

A

100 units/kg q12H
or
200 units/kg q24h

CrCl <30 ml/min = contraindicated

71
Q

Fondaparinux dosing VTE

A

<50kg: 5mg q24H
50-100kg: 7.5mg q24H
>100kg: 10mg q24H

CrCl <30 ml/min = contraindicated

72
Q

Apixaban and Rivaroxaban dose reduction after 6 months of VTE therapy

A

Can go to apixaban 2.5mg BID or rivaroxaban 10mg for extended-phase treatment

73
Q

Provoked VTE duration of therapy

A

3 months

74
Q

First episode of Provoked VTE by persistent risk factor

A

At least 3 months, then reassess for extended-phase -
If low risk of bleeding and adherent, then low-dose apixaban/rivaroxaban preferred

75
Q

First episode of VTE with thrombophilia (inherited or acquired) duration

A

At least 3 months, then reassess for extended-phase
Low risk of bleed = continue

76
Q

First episode of cancer-related VTE duration

A

At least 3-6 months, extended if active cancer

LMWH preferred over DOAC if GI cancer

77
Q

Second provoked/unprovoked VTE duration

A

Indefinite

78
Q

Provoked VTE risk factors

A

Surgery
Hospitalization
Plaster cast immobilization within 3 months
Estrogen
Pregnancy
Prolonged travel >8 hours
Lesser leg injuries
Immobilization within 6 weeks

79
Q

Fresh Frozen Plasma dose for warfarin reversal

A

15-20 mL/kg (around 1.2-1.6L)

Critically ill: 30 mL/kg

80
Q

3-factor Clotting factors

A

II IX X

81
Q

4-factor Clotting factors

A

II VII IX X

82
Q

Activated PCC factors

A

II VIIa IX X

83
Q

Cryoprecipitate

A

Thaw 1 unit of FFP in cold conditions

Factor VII, XIII, von Willebrand factor, fibronectin, fibrinogen

0.2 units x kg = 1 g/dL increase in fibrinogen

84
Q

Recombinant activated factor VII

A

Reversal for UFH, LMWH, DOAC

90 mcg/kg
18-30 mcg/kg documented as ok and cheaper

85
Q

Protamine for UFH

A

Reversal for UFH

1mg protamine neutralizes ~100 units heparin received in past 2 1/2 hours

Max dose 50mg

86
Q

Packed RBCs

A

1 unit = Hgb increase 1-2 g/dL

87
Q

Platelets

A

1 unit = 300,000-600,000 platelets

88
Q

Protamine for LMWH

A

Reverses ~50-60%

1mg protamine neutralizes 1mg of enoxaparin

If LMWH administered <8 hours before, then give standard dose

If LMWH administered >8 hours before need for reversal, give 0.5mg protamine for every 1mg enoxaparin

89
Q

Vitamin K

A

Warfarin reversal

Delayed onset

PO takes 24-48 hours

IV (as slow infusion) takes 8-12 hours

Avoid SC/IM

90
Q

4PCC dosing for warfarin

A

ABW

INR 2-4: 25 units/kg (max 2500)
INR 4-6: 35 units/kg (max 3500)
INR >6: 50 units/kg (max 5000)
INR <2 with cerebral bleed: 12.5-25 units/kg

91
Q

aPCC dosing for DOAC

A

25-50 units/kg

92
Q

Dabigatran preprocedural hold time

A

Low/mod bleed risk surgery
CrCl >= 50 = 1 day
CrCl <50 = 2 days

High bleed risk surgery
CrCl >= 50 = 2 days
CrCl <50 = 4 days

93
Q

DOAC preprocedural hold time

A

Low/mod bleed risk surgery = 1 day

High bleed risk surgery = 2 days

94
Q

Idarucizumab

A

Antidote for DTI (dabigatran)

5g IV

95
Q

Andexanet alfa

A

Coagulation factor Xa (recombinant), inactivated

Antidote for factor Xa inhibitors

96
Q

Low dose andexanet alfa

A

400mg IVB followed by 4mg/min for 2 hours

Use if last dose of apixaban 5mg or less or rivaroxaban 10mg or less administered less than 8 hours earlier or unknown

97
Q

High dose andexanet alfa

A

800mg IVB followed by 8mg/min for 2 hours

Use if last dose of apixaban >5mg or rivaroxaban >10mg taken less than 8 hours before or unknown

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