Anticoagulation Flashcards
B/G, Indication, MOA. Facts
Heparin
MOA
Prophy
Txt of VTE and ACS
Antidote
SE
Monitoring
MOA: binds to AT then inactivates thrombin factor 2a and 10a. prevent fibrin conversion.
Prophy: 5k sc q8-12
Txt VTE: 80u/kg bolus then 18 u/kg infusiob
TxtACS: 60u/kg bolus then 12u/kg infusion
Antidote: Protamine (1mg will reverse 100u. max 50mg)
SE: Bleeding, Thrombocytopenia, HIT, Hyper K, osteoporosis (long term)
Monitor: aPTT q 6 hrs (1.5x - 2 control) or anti-Xa, Plt, Hgb, Hct
Enoxaparin
Brand
BBW
MOA
Prophy
Txt of VTE
SE:
Monitor
Brand: Lovenox
Boxed warnings: spinal puncture; risk of hematomas and paralysis
MOA: binding to AT and have a greater affinity to Xa than 2a
Prophy: 30mg sc q 12h or 40mg qd (Crcl less than 30: 30mg SC qd)
Txt of VTE: 1mg/kg sc q 12 or 1.5mg/kg sc qd (CrCl less than 30: 1mg/kg sc qd)
SE: bleeding, thrombocytopenia, HyperK, Increase LFTs
Monitor: Scr Anti-Xa (in pregnancy)
Antidote: Protamine
DO NOT EXPEL THE AIR BUBBLES
Deltaparin
Brand?
MOA
Fragmin
MOA: binding to AT and have a greater affinity to Xa than 2a
HIT
Can lead to a prothrombotic state.
Dx: unexplained drop in PLT (50% from baseline)
Stop all forms of heparins; stop warfarin and start vit K)
Start argatroban
Apixaban
Brand, BBW, MOA, Afib, Txt of DVT/PE, warning
B: Eliquis
BBW: risk of hematomas and paralysis with spinal puncture (ALL direct Xa inhibitors); risk of thrombotic events with premature d/c
Warning: not recommended in prosthetic heart valve. (Use warfarin)
MOA: Direct Xa inhibitor
Afib: 5mg BID; Unless pt is 2 of 3: over 80, under 60kg, or SCr 1.5 then 2.5 BID
Txt of DVT/PE: 10mg BID x 7d then 5mg BID
Betrixaban
Brand, indication, warning
Brand: Bevyxxa
Warning: not recommended in prosthetic heart valve. (Use warfarin)
indicated for prophylaxis of DVT prophy in hospital and extended care
Edoxaban
Brand, warning, Afib dosing
Brand: Savaysa
BBW: reduce efficacy in CrCl greater than 95 ml/min
Warning: not recommended in prosthetic heart valve. (Use warfarin)
AAfib: CrCl over 95; do not use
51-95: 60mg qd
15-50: 30mg qd
less than 15 do not use
Rivaroxaban
Brand, Afib, DVT, Missed dose, DI
Xarelto, Xarelto Starter pack (use for DVT txt)
doses above = to or above 15 take with food
Afib: CrCl> 50ml/min; 20mg qd WITH FOOD
15-50: 15mg qd WITH FOOD
Txt of DVT/PE: 15mg po BID x 21 days then 20mg qd.
BID Missed dose: if taking 15mg BID then ta)ke both as soon as you remember then resume.
DI: A major 3A4 substrate and p-gp
Fondaparinux
Brand; Contraindication
Arixtra
CrCl less than 30: do not use
Conversion between AntiCoag
going from warfarin to another Anticoag:
R: Rivaroxaban when INR is less than 3
E: Edoxaban when INR is less than 2.5
A: Apixaban when INR is less than 2
D: Dabigatran when INR is less than 2
Dabigatran
brand, afib, se, antidote, counseling point
Pradaxa
MOA: Direct 2a inhibitor
afib: 150mg BID
15-30 crcl: 75mg bid
less than 15 do not use.
SE: gastritis-like symptoms
Antidote: Praxabid (Idarucizumab)
CP: Take with full glass of water! KEEP IN OG CONTAINER IF dose is less than 6 h skip
Argatroban
Indication, MOA
Indication: HIT or PCI at risk for HIT
MOA: Direct thrombin inhibitor
Bivalirudin
Brand, indication MOA
Angiomax
Indication: ACS undergoing PCI (preferred if undergoing cardiac surgery)
Desirudin
Brand, Indication
Iprivask
VTE prevention after hip arthrolplasty
Warfarin
Brand, MOA, active enatiomer, SE
Coumadin, Jantoven
MOA: competitively inhibit VKORC1 to decrease SNOT and protein C&S
S-enatiomer more potent
SE: skin tecrosis, Purple toe syndrome
Highly protein bound 99%
Warfarin
Dosing, Warnings, Goal Antidote
Healthy pt: 10mg qd x 2 days then adjust
start 5mg or less in: Elderyl, 3a4 inhibitors, liver disease, HF, malnorished.
warnings: HIT (contraindicated as monotherapy in HIT) Presence of 2C92/3 or polymorphism of VKORC1
INR: 2-3 ;2.5-3.5 for mechanical mitral valve or 2 mechanical heart valve
antidote vit k
Warfarin color
Pink 1mg Lavender 2mg Green 2.5mg Brown 3mg Blue 4mg peach 5mg Teal 6mg yellow 7.5 mg white 10mg
5 G’s that increases bleeding risk
Garlic, Ginseng, ginko, ginseng, glucosamine
Warfarin use in DVT
Begin warfarin with parenteral anticoag for a min of 5 days AND until INR is greater than 2 for at least 24 hours
Protamine
1mg will reverse 100u of heparin
Idarucizumab
brand, use
Praxabind
pradaxa antidote
Vitamine K/Phytonadione
Brand, SE, SC, IM
Mephyton
SE: Anaphylaxis
SC route not recommended due to variable absorption
IM route causes hematoma
Four Factor Prothrombin Complex Concentrate
Brand, Factors, coadmin with?
kCENTRA
Has factors SNOT and protein C&S
Admin Vit K at the same time
Factor 7a recombinant
NovoSeven RT
Vit K use
INR above 4.5 reduce or skip warfarin dose
4.5-10 w/o bleeding: Hold 1 - 2 doses of warfarin
10 w/o bleeding: Hold warfarin. Give ORAL vit K 2.5 - 5mg
Major bleeding from warfarin: Hold warfarin.. Give Vit K 5 - 10mg by SLOW IV and Kcentra
bridging therapy
means stop warfarin therapy and using LMWH or UFH for short period to prevent clotting
VTE Risk factors
Surgery, Immobility, Cancer/chemotherapy, pregnacy, ESA, Estrogen, hx of VTE, major trauma.
Long Distant travel prophy
Use exercise. not aspirin or anticoag
VTE Txt
Should be treated for 3 months
W/o cancer: R.E.A.D are preferred over warfarin for DVT or PE
W/ Cancer: LWMH are preferred over all anticoags (including warfarin)
Aspirin is recommended for 2nd prophy is VTE was unprovoked
CHADS2
CHF = 1 , HTN = 1, Age >75 = 1, Diabetes = 1 S = stroke or TIA = 2
score of:
0 = no therapy
1 = oral anticoagulation rather than anti platelets
2 or more: oral anticoags indefinitely.
CHA2DS2VASc
Age 75 yo or older = 2, Vascular disease (prior MI. PAD, aortic plaque) = 1, Age = 65 - 74 years Sex Category female = 1
Score of:
0 = No anticoag
1 = ASA may be cosidered
2 or more = Oral coag is recommended. (R.E.A.D)
