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Theraputics Winter > Anticoagulation Acute VTE > Flashcards

Anticoagulation Acute VTE Flashcards

1
Q

What are some hypercoagulable conditions

A

PRIMARY
ATIII def
Protien C and S def
Factor XII def
Factor V (genetic Leiden)
Increased factor VIII
Prothrombin mutation (G20210A)
SECONDARY
Pregnancy, Immobile, Trauma, Oral contraceptives Anitphospholipid syndrome, cancer, HITTS

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2
Q

DVT signs and symptoms

A

Unilateral swelling and + Homan sign ( flex foot and pain behind calf = DVT )
Palpable cord

Doppler sounds and B mode visual
Elevated D dimmer (((≤240 normal )))
Wells score of ≤2

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3
Q

Pulmonary embolism (PE) signs and symptoms

A

Dyspnea
Tachy pnea and cardia
Chest pain and tightness

V/Q scan mismatch
Elevated D- dimmer
Simplified wells score of >4

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4
Q

Wells score scoring

A

≤0 low with 5% DVT
1-2 moderate with 17% DVT
≥3 likely with 17-53% DVT

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5
Q

DVT flow chart for treatment

A
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6
Q

Wells PE score meaning

A

≤4 unlikely 12.1%
≥4 likely 37.1%

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7
Q

PE flow chart

A
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8
Q

VTE treatment flow chart

A
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9
Q

What do you do when you have PE with cardio compromise or DVT with high limb loss

A

Fibrinolytic + UFH or LMWH

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10
Q

If pt negative for DVT (limb loss) and PE (cardio complication) but actively bleeding
In addition to being contra with anticoagulant
And it being a lower extremity?

A

Place IVC filter
Initiate anticoagulant when bleeding stops (if not CI)
Remove IVC

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11
Q

If no to bleeding and sever DVT and PE with complication what do you do
And pt has PE with poor prognosis or DVT inpatient?

A

CrCl <30 - UFH for 5 days overlap with warfarin and INF >2
Crcl >30 UFH for 5 days overlap with warfarin and INF >2 and UFH with transition to DOAC

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12
Q

Outpatient VTE medications

A

Rivaroxaban
Apixaban
LMWH/ fondaparinux x 5 days then dabigatran or edoxaban
LMWH/ fondaparinux x 5 days overlap with warfarin and INR >2

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13
Q

What is the one of the concerns for fibrinolytic usage?

A

Not site specific and can trigger hemmoragic events
X in pt that has a ischemic stroke before
X bleeding or injury in the last 3 months

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14
Q

What dose of heparin needs to be given with what drug therapy

A

Fibrinolytic need a high intensity heparin
LD - 80 units/kg iv bolus MX 10,000 (125 kg)
MD - 18 units/kg/hour MX 2150 units/hr (120 kg)
NOTE
Can stop or keep but in US we stop heparin when starting fibrinolytic

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15
Q

Alteplase dose and place in therapy

A

MAIN DRUG USED FOR DVT or PE
PE: 100mg IV over 2 hours
Cardiac arrest: 50 mg IV bolus

Stop heparin for those 2 hours then continue

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16
Q

What are the fibrinolytic?

A

Alteplase (t-PA)
Tenectaplase (TNK)
Streptokinase
Urokinase

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17
Q

VTE treatment strategies (picture)

A
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18
Q

Oral only treatment for VTE (Apixban)

A

0-7 days
Apixaban 10mg BID for 7 days

8-90 days
Apixaban 5mg BID

91+
Apixaban 2.5mg BID

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19
Q

Oral only treatment for VTE (Rivaroxaban)

A

0-7 days
Rivaroxaban 15mg BID for 21 days

8-90 days
Rivaroxaban 20mg QD

91+
Rivaroxaban 10mg QD

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20
Q

Switch treatment for VTE

A

0-7 days
UFH, LMWH or Fondaparinux for 5-10 days

8-90 days
Dabigatran 150mg BID or edoxaban 60mg QD
If dont want to wait the 5- 10 days can use apixaban or Rivaroxaban

91+
Dabigatran 150mg BID after first 6 months

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21
Q

Overlap therapy for VTE

A

0-7 days
UFH, LMWH or fondaparinux
Also starting warfarin QD overlapped with parental anti coagulation for at least 5 days and INR ≥2 and then
8-91+
Warfarin regiment

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22
Q

What part does heparin act on and do?

A

Requires AT III
Doesn’t dissolve cot just prevents it from growing

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23
Q

Labs needed to monitor heparin?

A

CBC
PT/INR
aPTT
BUN
Serum Creatinine
ROUTINE LABS
anti-Xa or aPPT and CBC with platelets

24
Q

UCSD goal aPPT and anti-Xa

A

aPPT - 50-77 seconds (UCSD)
Anti-Xa 0.3-0.7 IU/ml (EVERYWHERE)

25
Q

Heparin Adverse effects

A

HIT
Hemorrhaging

RARE
Hypersensitivity at injection site
Hyperkalemia
Osteoporosis

26
Q

What is used to reverse heparin?

A

Stopping infusion and adding protamine

27
Q

What are the options for LMWH?

A

Enoxaparin
Dalteparin

28
Q

DVT/PE for dose Enoxaparin?

A

Lovenox (LMWH) - mainly used
1 mg/kg SC BID
1.5-2 mg/kg SC daily

NEEDS TO BE RENAL ADJUSTED

29
Q

DVT/PE dose for dalteparin?

A

Fragments (LMWH)
Month 1: 200 IU/kg SC daily (MX 18,000)
Month 2-6 150 IU/kg SC daily (MX 18,000)

NEEDS TO BE RENAL ADJUSTED

30
Q

What is the benefit of LMWH in term of monitoring?

A

So stable do not really need to monitor only need to monitor in high risk pts

31
Q

What pts need to be monitored and what do we use for LMWH?

A

We use anti-factor Xa
Obese
Renal impairment Crcl <30
Elderly and children
Cancer

32
Q

How do you know a patient is in HIT?

A
  1. 50% drop from baseline of plt
  2. Venous or arterial thrombosis
  3. Skin lesion at heparin inj sites
  4. Acute systemic reaction after a bolus of IV heparin
33
Q

HAT vs HIT

A

Hat <4 days after dose
UNLESS
They have had heparin in the last 3 months
Not a huge plt drop and can recover and still use heparin

Hit 4-14 days
Need to stop all treatment

34
Q

What are the alternatives for a pt with HIT

A

Direct thrombin inhibitor like
Argatroban, bivaliruden and fondaparinux

35
Q

What are the 4 T in the T test and what do they say about HIT

A

Thrombocytopenia, timing, thrombosis, the other causes
≤ 3 - ≤5% chance of HIT
4-5 - 14% chance of HIT
6-8 - 64% chance of HIT

36
Q

What pts do I uses the direct thrombin inhibitors for HIT

A

Fondaparinux - avg pt with low risk of bleeding

Bivalirudin and Argatroban - CrCl <30, high risk bleeding, life threatening clots, urgent procedure

37
Q

When do I transition to oral for HIT pts

A

≥ 1500 plt count and continue for 1 month till plts reach 1500
3-6 months if acute thrombosis
> 6 months if another indication for anticoagulation

38
Q

Fondaparinux dosing for DVT/PE

A

Weight < 50 kg: 5mg SC daily
Weight 50-100 kg: 7.5 mg SC daily
Weight > 100 kg 10 mg Sc daily

X CLcr 30 mL/min

39
Q

Benefits and use for Bivalirudin

A

Used for CABG or HIT
PRO 80% proteolytic cleavage 20% renal excretion
25 min H/L

40
Q

Benefits and use for Argatroban

A

Use for pts with HIT
Needs to hepatic adjusted
aPPT range of 60-90

41
Q

Dose for Bivaliruden and Argatroban

A

Bivaliruden - .15mg/kg/hr
.08 for 60-30
.05 for 30
.14 hepatic
Argatroban - 1mcg/kg/min Icu non its doubled

42
Q

How does Argatroban and Bivaliruden affect INR and aPPT

A

Increase INR
Changes aPPT range from 50-77 to 60-90

43
Q

Would you transition a pt from Argatroban or Bivalirudin to Coumadin?

A

No because of the increase INR effect of direct thrombins inhibitors

44
Q

Dabigatran Brand, elimination, dose, AD, and Reversibility

A

Pradaxa
Hepatic 80%
CLcr >30 - 150 PO BID
CLcr ≤30 DO NOT USE
CLcr < 50 with use of P-gp - AVOID

AD
Bleeding, GI, Rash, Hives

Reversible
Idaruxizumab, dialysis, PRBC’s

45
Q

Rivaroxaban Brand, elimination, dose, AD, and Reversibility

A

Xarelto
Hepatic mainly
CLcr ≥ 15 - 15mg po BID for 21 days then 20 PO qPM
CLcr < 15 - DO NOT USE
reoccurrence - dose CLcr > 15 10mg PO after 6 months of standard dosing

AD
Bleeding, back pain, RARE osteoporosis

Reversible
Andexanet Alfa, PRBC, 4-factor PCC

46
Q

Apixaban Brand, elimination, dose, AD, and Reversibility

A

Eliquis
Mainly hepatic
10 mg po BID for 7 days then 5 mg PO BID
reoccurrence - 2.5 PO BID after at least 6 months of standard dosing

AD
Bleeding

reversible- andexant Alfa, PRBC, 4-factor PCC

47
Q

Edoxaban Brand, elimination, dose, AD, and Reversibility

A

Savaysa
50% 50% hepatic and renal

CLcr > 50 - >60 kg give 60mg po QD
CLcr 15-50 or ≤ 60kg with P-go inhibitors 30mg
CLcr <15 DO NOT USE

AD
Bleeding

Reversible- PRBC, 4-factor PCC

48
Q

Why do we need to bridge warfarin?

A

Because of the long H/L of factor II and we need to wait for all the factors to be deselected

49
Q

What is the typical INR range

A

2-3

50
Q

Warfarin staring dose for all races and ages

A

Age > 70 black - 7.5, white - 5, Asian - 2.5
Age <70 Black -5, white - F-2.5 M-5, Asian - 2.5

51
Q

When we reduce warfarin and by now much?

A

Decrease by 2.5
Weight < 45
BaseINR > 1.3
Malnourished
Albumin <3
Liver disease
Catabolic conditions
taking azoles, metronidazole, Sentra or amiodarone

52
Q

When do we raise warfarin dose and by how much?

A

Increase 2.5
Weight >90 kg
Untreated hypothyroidism
Receiving enteral feeds
Taking rifampin, carbamazepine, dicloxacillin, phenobarbital and Bosentan

53
Q

DDI for warfarin increasing metabolism

A

Increase dose of warfarin for
PCPRS
rifampin, carbamazepine, dicloxacillin, phenobarbital and Bosentan

54
Q

Drugs decreasing warfarin metabolism?

A

Decrease dose of warfarin
Aminodrone
Cimetidine
Cipro
Erythromycin
Fluconazole
Fluvastatin
Ginseng
Azoles
Trimethoprim/ sulfamethoxazole

55
Q

What are some pt educations about warfarin?

A

Sustain injury or fall seek medical attention
Intake of vitamin K changes warfarin consistent
Only 1 alcohol per day

56
Q

Protaime dosage for 1,200 units

A

60 mins half life and
Take 5 HL back and add up and divided by 100
1200, 600, 300, 150, 75 = 2325 / 100 - 23g of protamine

Theraputics Winter (12 decks)

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