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NAPLEX Review > Anticoagulation > Flashcards

Anticoagulation Flashcards

1
Q

What is an embolus?

A

When a clot or a piece of a clot travels to another location

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2
Q

What factors does warfarin inhibit?

A 
SNOT
Seven
Nine
Ten (10)
Two
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3
Q

What factors do rivaroxaban, apixaban, edoxaban, and betrixaban inhibit?

A

Xa

All have xa in their name

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4
Q

What factors do UFH inhibit?

A

Xa and IIa

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5
Q

What factors do LMWH inhibit?

A

Xa and IIa (more X than II)

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6
Q

What factors do argatroban, bivalirudin, and dabigatran inhibit?

A

IIa (thrombin)

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7
Q

DOAC vs Warfarin

Which has less drug drug interactions?

A

DOAC

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8
Q

DOAC vs Warfarin

Which has shorter half life?

A

DOAC

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9
Q

DOAC vs Warfarin

For which one is dosing based on the indication and liver/hepatic function?

A

DOAC

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10
Q

DOAC vs Warfarin

Which one is dosed based on INR?

A

Warfarin

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11
Q

When to use DOAC vs Warfarin

A

DOAC: stroke prophylaxis in afib if CHADSVASC >/ 2 (men) or 3 (women); VTE treatment
Warfarin: if moderate/severe mitral stenosis or mechanical heart valve
If patient has cancer and VTE, use LMWH

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12
Q

What factor does fondaparinux inhibit?

A

Xa indirectly via antithrombin

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13
Q

What is the drug of choice in someone with HIT?

A

argatroban

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14
Q

What decrease in Hgb can indicate a bleed?

A

> /2

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15
Q

What drugs increase bleeding risk?

A

Anticoagulants, antiplatelets, NSAIDs, natural products (e.g. ginkgo), SSRIs, SNRIs

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16
Q

Unfractionated heparin MOA

A

binds to antithrombin (AT) which inactivates factor IIa (thrombin) and Factor Xa and prevents the conversion of fibrinogen to fibrin

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17
Q

Unfractionated heparin prophylaxis and treatment of VTE dosing - use what body weight?

A

Prophylaxis: 5000 units SQ q8-12h
Treatment: 80 units/kg IV bolus then 18 units/kg/hr
Use total body weight

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18
Q

Unfractionated heparin CI, Warnings, SE

A

CI: active bleeding, severe thrombocytopenia, history of HIT
Warnings: Fatal medication errors
SE: Bleeding, thrombocytopenia, HIT, alopecia, hyperkalemia, osteoporosis (long term use)

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19
Q

Unfractionated heparin antidote

A

protamine

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20
Q

Why should you not given unfractionated heparin IM?

A

Risk of hematoma

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21
Q

Low molecular weight heparin drugs and MOA

A

MOA: bind to antithrombin which inactivates factor Xa and Factor IIa
Drugs: Enoxaparin, dalteparin

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22
Q

LMWH BBW, CI, SE

A

BBW: patients receiving neuraxial anesthesia (epidural, spinal) or undergoing spinal puncture d/t risk of hematoma and paralysis
CI: History of HIT, active bleed
SE: BLeeding, anemia, injection site reactions, decreased platelets

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23
Q

When should you monitor anti Xa levels when using LMWH?

A

In pregnancy

Also obesity, low body weight, pediatrics, elderly, or renal insufficiency

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24
Q

LMWH antidote

A

protamine

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25
Q

What medications are used to break down clots but have a low risk of bleeding?

A

Fibrinolytics

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26
Q

HIT is an immune mediated reaction that involves which immunoglobulin

A

IgG

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27
Q

HIT vs HITT

A

Heparin induced thrombocytopenia

Heparin induced thrombocytopenia + thrombosis

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28
Q

Typical onset of HIT

A

5-14 days

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29
Q

If a patient is diagnosed with HIT and they are on warfarin, what should you do and why?

A

D/c warfarin and give vitamin K

Warfarin use with low platelet count has a high correlation with warfarin-induced limb gangrene and necrosis

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30
Q

When can you start warfarin in someone who was diagnosed with HIT?

A

When platelets have recovered to >150,000

Overlap with non-heparin anticoagulant for at least 5 days until INR is within goal for >24 hours

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31
Q

Apixaban (Eliquis) dosing for
Nonvalvular afib
Treatment of DVT/PE

A

Nonvalvular afib: 5mg PO BID (2.5mg in certain populations)

Treatment of DVT/PE: 10mg PO BID x 7 days then 5mg PO BID

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32
Q

What to do if patient missed a dose of

Apixiban (Eliquis)

A

Take immediately on the same day and BID administration should be resumed
Do NOT double up

33
Q

What to do if patient missed a dose of

Rivaroxaban (Xarelto)

A

Administer ASAP on same day

If taking BID can double up on a dose - just maintain total daily dose

34
Q

What to do if patient missed a dose of

Edoxaban (Savaysa)

A

Take immediately on the same day

Do NOT double up

35
Q

What to do if patient missed a dose of

Betrixaban (Bevyxxa)

A

Take immediately on the same day

Do NOT double up

36
Q

Rivaroxaban dosing for
Nonvalvular afib
Treatment of DVT/PE

A

Nonvalvular Afib:

  • CrCl >50: 20mg daily with dinner
  • CrCl 15-50: 15mg daily with dinner
  • CrCl <15: avoid use

Treatment of DVT/PE: 15mg PO BID x 21 days then 20mg daily
- CrCl <30: avoid use

37
Q

Should rivaroxaban be taken with or without food?

A

Take dose 15mg and greater with food

38
Q

Edoxaban dosing for
Nonvalvular afib
Treatment of DVT/PE

A 
Nonvalvular Afib
- CrCl > 95: do NOT use
- CrCl 51-95: 60 mg daily
- CrCl 15-50: 30 mg daily
- CrCl <15: not recommended
Treatment of DVT/PE: 60mg daily starting 5-10 days after parenteral anticoagulation
39
Q

Oral direct factor Xa inhibitors BBW, CI, warnings, SE

A

BBW: patients receiving neuraxial anesthesia (epidural or spinal) or undergoing spinal puncture - risk for hematoma and paralysis; increased risk of thrombotic events with premature discontinuation
CI: active pathological bleeding
Warnings: Not recommended with prosthetic heart valves
SE: well tolerated, bleeding

40
Q

Antidote for apixaban and rivaroxaban

A

Andexanet alfa (Andexxa)

41
Q

When to d/c oral direct factor Xa inhibitors for elective surgery

A

Rivaroxaban, edoxaban: d/c 24 hours prior to elective surgery
Apixaban: d/c 28 hours prior to elective surgery with moderate-high bleeding risk or 24 hours before low bleeding risk

42
Q

Fondaparinux BBW, CI, SE

A

BBW: Patients receiving neuraxial anesthesia (epidural, spinal) or undergoing spinal puncture are at risk of hematomas and subsequent paralysis
CI: severe renal impairment (CrCl < 30 mL/min), active bleed, bacterial endocarditis
SE: bleeding, anemia, local injection site reactions, thrombocytopenia, hypokalemia, hypotension

43
Q

Fondaparinux antidote

A

None

44
Q

Conversion from warfarin to another oral anticoagulant

Stop warfarin and convert to ____ when INR is ____

A

Rivaroxaban <3
Edoxaban 2.5 or less
Apixaban <2
Dabigatran <2

45
Q

Conversion from oral Xa inhibitors (apix, edox, and rivaroxaban) to warfarin

A

Overlap Xa inhibitor with warfarin until INR is therapeutic

Stop Xa inhibitor and start parenteral anticoagulant and warfarin at next scheduled dose

46
Q

Conversion from dabigatran to warfarin

A

Start warfarin 1-3 days before stopping dabigatran

47
Q

What medications are direct thrombin inhibitors?

A

Dabigatran
Argatroban
Bivalirudin

48
Q

What to do if patient missed a dose of

Dabigatran (Pradaxa)

A

Take ASAP unless it is within 6 hours of the next dose

Do NOT double up

49
Q

Dabigatran (Pradaxa) dosing for
Nonvalvular afib
Treatment of DVT/PE

A

Nonvalvular afib
150mg BID
CrCl 15-30: 75mg BID
CrCl <15: no recommendations

Treatment of DVT/PE
150mg BID starting 5-10 days after parenteral anticoagulation
CrCl < 30: no recommendation

50
Q

Dabigatran (Pradaxa) BBW, CI, SE

A

BBW: Patients receiving neuraxial anesthesia (epidural, spinal) or undergoing spinal puncture are at risk of hematomas and subsequent paralysis; premature d/c increases thrombotic risk
CI: active pathological bleeding, mechanical heart valve
SE: dyspepsia, gastritis-like symptoms, bleeding

51
Q

Dabigatran (Pradaxa) antidote

A

idarucizumab (praxbind)

52
Q

What DOAC needs to be dispensed in it’s original container?

A

Dabigatran (Pradaxa)

53
Q

What medications are safe to use in patients with HIT?

A

argatroban and bialirudin

54
Q

Warfarin MOA

A

competitively inhibits vitamin K epoxide reductase (VKORC1) enzyme complex causing depletion of active clotting factors II, VII, IX, and X

55
Q

What to do if a patient misses a dose of warfarin?

A

Take ASAP on the same day

Do not double dose the next day

56
Q

Warfarin BBW, CI, warnings, SE

A

BBW: major or fatal bleeding
CI: pregnancy (except with mechanical heart valve at high risk of clot), uncontrolled HTN, recent eye surgery or CNS, possible miscarriage
Warnings: tissue necrosis/gangrene, HIT, presence of CYP2C9*2 or *3 alleles and/or polymorphism of VKORC1 gene may increase bleeding risk
SE: bleeding/bruising, purple toe syndrome

57
Q

What is the typical warfarin INR goal? When should it be higher?

A

Typical: 2-3

Higher if mechanical mitral valve or 2 mechanical heart valves

58
Q

Warfarin antidote

A

Vitamin K (phytonadione)

59
Q

What warfarin tablet color is associated with each dose?

A 
Please Let Greg Brown Bring Peaches To Your Wedding
Pink 1 
Lavender 2
Green 2.5
Brown 3
Blue 4
Peach 5
Teal 6
Yellow 7.5
White 10
60
Q

What medications decrease INR while on warfarin

A

aprepitant, bosentan, carbamazepine, phenobarbital, phenytoin, primidone, rifambin, licorice, and st. john’s wort

61
Q

What medications increase INR while on warfarin

A

amiodarone, azole antifungals, capecitabine, etravirine, fluvastatin, fluvoxamine, macrolide, abx, metronidazole, bactrim

62
Q

What foods are high in vitamin K?

A

Broccoli, brussel sprouts, cabbage, spinach, tea (green/black)
Green leafy veggies

63
Q

What natural supplements increase bleeding risk while on warfarin?

A

Garlic, ginger, ginkgo, ginsent, glucosamine

Bromelain, don quai, vitamin D, high dose fish oil, willow bark, wintergreen oil

64
Q

What natural supplements decrease bleeding risk while on warfarin?

A

Alfalfa, green tea, coenzyme Q10, st john’s wort

65
Q

Protamine sulfate indication, BBW, SE

A

Indication: UFH/LMWH reversal
BBW: hypersensitivity
SE: hypotension, bradycardia, flushing, anaphylaxis

66
Q

Idarucizumab indication, warnings, SE

A

Indication: dabigatran (Pradaxa) reversal
Warning: thromboembolic risk
SE: HA, low K, delirium, constipation, fever

67
Q

Andexanet alfa indication, BBW, SE

A

Indication: apixaban and rivaroxaban reversal
BBW: thromboembolic risks, ischemic events, cardiac arrest, sudden death
SE: injection site reaction, DVT, ischemic stroke, UTI, pneumonia

68
Q

Vitamin K (phytonadione) indication, BBW, SE

A

Indication: warfarin reversal
BBW: hypersensitivity reactions (rare)
SE: anaphylaxis, flushing, rash, dizziness

69
Q

Four factor prothrombin complex concentrate (Kcentra) indication, BBW< CI, warnings, SE

A

Indication: warfarin reversal
BBW: arterial and venous thromboembolic complications
CI: disseminated intravascular coagulation (DIC) and known HIT
Warnings: made from human blood and may carry risks of transmitting infectious agents
SE: HA, N/V/D, arthralgia, hypotension, low K, thrombotic events

70
Q

When to use IV vs PO vitamin K to reverse warfarin?

A

INR <4.5 - skip warfarin dose and monitor
INR 4.5-10 and no bleeding: hold 1-2 doses warfarin and monitor
INR >10 and no bleeding - hold warfarin and give vitamin K
INR at any level and major bleeding 5-10mg IV vitamin K and Kcentra

71
Q

When to stop warfarin before major surgery

A

Stop ~5 days before surgery
Can bridge with LMWH or UFH (d/c LMWH 24 hours before surgery and UFH 6 hours before surgery)
Resume warfarin 12-24 hours after surgery

72
Q

How long should VTE be treated for?

A

3 months if known cause of VTE

if unknown cause of VTE can treat for longer if not high bleeding risk

73
Q

What medications are preferred in patients without cancer? With cancer?

A

Without: dabigatran, rivaroxaban, apixaban, and edoxaban
With: LMWH

74
Q

Patients with mechanical heart valves and atrial fibrillation/flutter are anticoagulated with what?

A

Warfarin only because they are high risk

75
Q

What does CHADSVASc stand for?

A 
CHF
HTN
Age>/75 years - 2
Diabetes
Stroke/TIA prior - 2
Vascular disease (MI, PAD, aortic plaque)
Age 65-74
Sex, female
76
Q

What are the CHADSVASc risk categories and recommended therapies?

A 
Score 0 (M) or 1 (F): no anticoagulation recommended
Score 1 (M) or 2 (F): Oral anticoagualtion may be considered
Score 2 (M) or 3 (F): Oral anticoagulation recommended; DOAC preferred
77
Q

What anticoagulant medications are preferred in pregnancy? Which are contraindicated?

A

Preferred: LMWH (DOC), UFH, pneumatic compression
CI: warfarin (may use during second/third trimester and change back to LWMH close to delivery)
DOACs have not been studied and are not recommended

78
Q

Which anticoagulant should be kept in the original bottle and not put in a pill organizer?

A

dabigatran

NAPLEX Review (79 decks)

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