Anticoagulation 2

Question 1

How is warfarin bridge to other anticoagulants (READ)

Answer 1

Rivaroxaban: Stop warfarin when INR is 3 or less
Edoxaban: Stop warfarin when INR is 2.5 or less
Apixaban: Stop warfarin when INR is 2 or less
Dabigatran: Stop warfarin when INR is 2 or less

Question 2

How are oral Xa inhibitors bridged to warfarin

Answer 2

1) Overlap Xa inhibitor with warfarin until INR is therapeutic
2) Stop Xa and start parenteral anticoagulation and warfarin at the same time

Question 3

How is warfarin started in healthy patients

Answer 3

10 mg a day for 2 days then adjusted based on INR

Question 4

What is the usual goal INR, mechanical valves

Answer 4

2 to 3, 2.5 to 3.5

Question 5

What enzyme is affected by warfarin

Answer 5

CYP2C9

Question 6

What are Herbal/Natural Products that increase INR (HINT: 5Gs)

Answer 6

Ginseng, Ginkos, Garlic, Glucosamine, Ginger

Question 7

How is warfarin therapy used for DVT/PE when it is being used with a parenteral anticoagulation (Heparin and LMWH)

Answer 7

Same day as parenteral therapy: Continue anticoagulation for a minimum of 5 days until the INR is greater than or equal to 2 for 24 hours

Question 8

If a patient opens a bottle of pradaxa how long do they have to take it

Answer 8

120 days (4 months)

Question 9

What can be used to test Heparin efficacy

Answer 9

AntiXa and APPT

Question 10

What drug should be avoided if a person has extremely good renal function

Answer 10

Edoxaban

Question 11

If a person has had a DVT and they are taking Warfarin what is the goal INR, how long should they take it

Answer 11

2-3 for 3 months

Question 12

What are the drugs associated as CYP2C9 inhibitors, therefore increasing the risk of bleeding with Warfarin use (HINT: MAT)

Answer 12

M: Macrolides, metronidazole
A: Azoles, amiodarone
T: TMP/SMX (Bactrim)

Question 13

If the INR is out of range but there is no major bleeding what should be done

Answer 13

Warfarin doses can be skipped until INR is corrected

Question 14

If the INR is out of range and greater than 10 what should be done

Answer 14

Hold warfarin and Give oral Vitamin K 2.5 to 5 mg EVEN IF NOT BLEEDING

Question 15

If the patient is having a major bleed and is on warfarin what should be done

Answer 15

Give Vitamin K 5 to 10 mg by slow IV injection AND 4 Factor prothrombin complex concentrate (4PCC)

Question 16

What are the LMWH

Answer 16

Enoxaparin and Dalteparin

Question 17

What is the antidote for Warfarin

Answer 17

Mephyton/Phytonadione (Vitamin K)

Question 18

What are the benefits of LMWH over Heparin

Answer 18

Do not require routine monitoring, LMWHs are cost effective, more predictable response

Question 19

When is LMWH usually monitored

Answer 19

Pregnant patients, patients with extreme body weight, patients with renal impairment

Question 20

What is a long term side effect of using Heparin

Answer 20

Osteoperosis

Question 21

What are the CYP 2C9 inducers

Answer 21

Phenytoin, Rifampin, carbamezapine, St. John’s Wart

Question 22

What do the CYP 2C9 inducers do when a patient is concurrently taking Warfarin

Answer 22

Decreases INR increasing the risk of clotting

Question 23

For patients who are traveling what is the best way to prevent VTE if traveling

Answer 23

Calf exercise

Question 24

T/F: Major surgery can increase the risk of clotting

Answer 24

True

Question 25

If a patient is having Heparin-Induced Thrombocytopenia what are the steps that should be taken

Answer 25

Stop the Heparin/LMWH
Stop Warfarin if being given
Administer Vitamin K if warfarin was also given
(DON’T GIVE PLATELETS)

Question 26

T/F: Do not expel air bubbles from Enoxaparin when administering

Answer 26

True

Question 27

What does the CHADsVASC score tell you

Answer 27

Relative risk of stroke due to Atrial Fibrillation

Question 28

When treating an acute DVT with dabigatran (PRADAXA) or Edoxaban (Saveysa) what does the labeling for each drug state for use

Answer 28

Approved for use AFTER 5 to 10 days of parenteral anticoagulat

Question 29

What DOACs can be used for DVT without bridging

Answer 29

Apixaban and Rivaroxaban