Anticoagulation Flashcards
Which anticoagulants can be used in the setting of HIT?
Argatobran/Bivalirudin (direct thrombin inhibitors IV)
Signs of Heparin-induced thrombocytopenia → sudden drop in _____ by > ___ %)
confirm with serology and antibodies & list on patient’s allergy list!!!
Signs of Heparin-induced thrombocytopenia → sudden drop in platelets by > 50%
confirm with serology and antibodies &
list on patient’s allergy list!!!
CHADS-VASc:
risk stratification scale to determine patient’s risk of developing _____ and/or ____
> /=2 is moderate to high risk patient → start ______ for these patients
CHADS-VASc:
risk stratification scale to determine patient’s risk of developing embolism and/or stoke
> /=2 is moderate to high risk patient → start anticoagulation for these patients
HAS-BLED:
Bleeding risk scale; scored from 0 to 5 (__ is the highest → >/ = ___% annual bleeding risk)
Disadvantage: does not take into consideration _____
HAS-BLED:
Bleeding risk scale; scored from 0 to 5 (5 is the highest → >/ = 10% annual bleeding risk)
Disadvantage: does not take into consideration falls
Length of VTE therapy:
Long-term therapy = _ months (most common)
Extended therapy = > _ months (weigh bleeding risk vs benefit) only for pts w/ ____ bleeding risk
Length of VTE therapy:
Long-term therapy = 3 months (most common)
Extended therapy = > 3 months (weigh bleeding risk vs benefit) only for pts w/ low bleeding risk
Duration of VTE therapy:
Consider:
_____ risk stratification (___-____score) and risk factors
Duration of VTE therapy:
Consider:
bleeding risk stratification (HAS-BLED score) and risk factors
Provoked VTE: no ______ event
Unprovoked status: precipitated by surgery, pregnancy, estrogen therapy, reduced mobility > ___ days, hospital admission
Provoked VTE: no identifiable event
Unprovoked status: surgery, pregnancy, estrogen therapy, reduced mobility >3 days, hospital admission
Non-cancer vs cancer patient: DOAC > VKA (warfarin) > LMWH (no cancer); LMWH > VKA (warfarin) > DOAC (cancer pt)
provoked VTE therapy duration:
long-term: 3 months
unprovoked VTE therapy depends on _____ risk
depends on bleeding risk:
- Low/moderate bleeding risk = extended therapy > 3 months
- High bleeding risk = 3 months
Warfarin dose
___ mg PO x2 days then __ mg PO daily
Elderly/frail: ___-___mg PO daily
Warfarin dose
10 mg PO x2 days then 5 mg PO daily
Elderly/frail: 2.5-5mg PO daily
Warfarin is most beneficial for which patients?
noncompliant pts
Mechanical heart valves
CAD
Warfarin MOA:
Inhibits factors ___, ___, ___, ___ (contact activation pathway best for _______ heart valves)
Inhibits factors II, VII, IX, X (contact activation pathway best for mechanical heart valves)
Cons of Warfarin:
Various interactions w/ food + meds (d/t polymorphisms CYP2C9 & VKORC1)
Cons of Warfarin:
Various interactions w/ food + meds (d/t polymorphisms CYP2C9 & VKORC1)
Factors that increase/decrease warfarin (3)
Dietary vitamin K increase –> decrease warfarin
Alcohol increase –> increase warfarin
Smoking increase
–> decrease warfarin
Side effects of warfarin (3):
Side effects of warfarin (3):
- bleeding
- skin necrosis
- purple toe syndrome
Warfarin INR Goals:
VTE + afib: ___ to ___
Mechanical heart valve: ____ to ___
Warfarin INR Goals:
VTE + afib: 2-3
Mechanical heart valve: 2.5-3.5
Warfarin reversal
Vitamin K
Warfarin requires or does not require bridging with Lovenox?
Bridging with Lovenox required for a min. of 5 days in VTE indication b/c full therapeutic effects seen 5-7 days of initiation or dose changes
most commonly used DOACs:
- Apixaban (Eliquis)
- Rivaroxaban (Xarelto):
Apixaban (Eliquis) Dosing:
Stroke prophylaxis:
___ mg PO BID
Tx of DVT/PE:
____ mg PO BID x 7 days, then ___ mg PO BID
Apixaban (Eliquis) Dosing:
Stroke prophylaxis:
5 mg PO BID
Tx of DVT/PE:
10 mg PO BID x 7 days, then 5 mg PO BID
Rivaroxaban (Xarelto) Dosing:
Stroke prophylaxis:
CrCl > 50mL/min
____ mg PO daily w. Evening meal
Tx of DVT/PE:
___ mg PO BID x ___ days, then ___ mg PO daily;
CrCl < 30mL/min avoid use
Rivaroxaban (Xarelto) Dosing:
Stroke prophylaxis:
CrCl > 50mL/min 20 mg PO daily w. Evening meal
Tx of DVT/PE:
15 mg PO BID x 21 days, then 20 mg PO daily;
CrCl < 30mL/min avoid use
WHICH ANTICOAGULANT AM I?
Dose: renally adjusted + has an induction period for tx of DVT/VTE (high recurrence)
Falsely elevates aPTT and INR → not a red flag just a s/e
ANTIDOTE: Andexxa very expensive
Premature discontinuation increase risk of thrombotic events
DOACs
Why is Edoxaban not used often? Betrixaban?
Edoxaban: Small CrCl window so not used much
Betrixaban: expensive + long duration 35-42 days
Do DOACs require frequent monitoring for efficacy? What should you monitor in DOACs?
No frequent monitoring (patient prefer these)
Monitor: Hgb, Hct, SCr, LFTs q 3-6mos.
Which patients benefit from DOACs?
Active GI bleed, no bridging, renal dz, CAD: use Apixaban
Noncompliant pt: Rivaroxaban (once daily dosing)
When should DOACs not be used?
Not recommended w/ _____ ______ _____
Avoid in pts w/ severe _____ impairment
Warning: pt receiving ______ anesthesia (epidural, spinal) or ______ puncture → risk of _____
______ , ______
Not recommended w/ prosthetic heart valves
Avoid in pts w/ severe hepatic impairment
Warning: pt receiving neuraxial anesthesia (epidural, spinal) or spinal puncture → risk of hematomas
bleeding , anemia
ORAL Direct Thrombin Inhibitor:
Dabigatran (Pradax)
Dabigatran (Pradax) Dose:
Stroke prophylaxis:
___ mg BID or
___ mg BID for CrCL 15-30mL/min
Tx of DVT/PE:
___ mg BID after 5-10 days of parenteral anticoagulation
Dabigatran (Pradax) Dose:
Stroke prophylaxis:
150 mg BID or
75 mg BID for CrCL 15-30mL/min
Tx of DVT/PE:
150 mg BID after 5-10 days of parenteral anticoagulation
Does Dabigatran (Direct thrombin inhibitor) require frequent monitoring for efficacy?
No frequent monitoring
Which oral anticoagulant has the highest risk GI bleeding?
Dabigatran (Pradax)
Who should Dabigatran avoided in?
Avoid in active _____, pts w/ _____ _____ _____
Warning: Pts receiving _____ anesthesia (epidural/spinal) or _____ puncture → increased risk of _______;
Avoid in active bleeding, pts w/ mechanical prosthetic heart valves
Warning: Pts receiving neuraxial anesthesia (epidural/spinal) or spinal puncture → increased risk of hematoma;
Side effects of Dabigatran: (3)
Side effects of Dabigatran:
- Dyspepsia
- gastritis-like symptoms
- bleeding (GI)
What should you monitor in patient receiving dabigatran?
Monitor: Hgb, Hct, Scr
A patient has elevated aPTT, PT/INR while on Dabigatran, what is your concern?
Dabigatran can falsely increase aPTT, PT/INR. This is not a red flag.
Dabigatran antidote
Antidote: idarucizumab (Praxbind)
How should Dabigatran be stored?
Protect from _____; dispense in _____ container + discard after __ mos of opening.
Protect from moisture; dispense in original container + discard after 4 mos of opening.
WHICH ANTICOAGULANT? Active GI bleed, no bridging, renal dz, CAD: use Apixaban
Apixaban
WHICH ANTICOAGULANT? Noncompliant pt:
Rivaroxaban (once daily dosing) or warfarin
Pt has an elevated aPTT and INR on DOACs (apixaban/rivaroxaban) what is your concern?
Falsely elevates aPTT and INR → not a red flag just a s/e
Antidote for Apixaban/rivaroxaban?
ANTIDOTE: Andexxa very expensive
why shouldn’t DOACs be prematurely discontinued?
increase risk of thrombotic events
Cancer, Liver disease, coagulopathy, pregnancy: ____
Avoid Bridging/Parenteral: _______
Low compliance (once daily dosing): _____, ____ (has long half-life), ______ (downside: has low CrCl window)
Renal disease+CAD: _____, _____
GI bleed: ______
Thrombolytic therapy use: IV ____
CAD: ______, _____
Cancer, Liver disease, coagulopathy, pregnancy: LMWH
Avoid Bridging/Parenteral: DOACs (rivaroxaban or apixaban)
Low compliance (once daily dosing): rivaroxaban, warfarin (has long half-life),
edoxaban (downside: has low CrCl window)
Renal disease + CAD: warfarin, apixaban
GI bleed: apixaban
Thrombolytic therapy use: IV heparin
