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NAPLEX review 2024 RXPrep Book > Anticoagulation & Blood Disorders: Anticoagulation > Flashcards

Anticoagulation & Blood Disorders: Anticoagulation Flashcards

1
Q

Two pathways of coagulation cascade

A

Contact activation pathway (intrinsic) = minor pathway
Tissue factor pathway (extrinsic) = activated by tissue damage/trauma

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2
Q

Warfarin inhibits factors

A

2,7,9,10

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3
Q

DOAC work on factor

A

Xa

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4
Q

Direct thrombin inhibitors (DTI) work on…

A

Thrombin IIa

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5
Q

UFH and LMWH work on factors….

A

Xa and Thrombin IIa

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6
Q

DOACs vs Warfarin

A

Use warfarin if moderate-severe mitral stenosis or mechanical heart valve in stroke prevention for AF

Use warfarin if pt has antiphospholipid syndrome or mechanical heart valve in VTE treatment

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7
Q

UFH antidote

A

protamine

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8
Q

UFH ppx VTE dose

A

5,000 units SubQ Q8-12h

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9
Q

UFH txm VTE dose

A

80 units/kg IV bols, 18unit/kg/hr infusion

use TBW

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10
Q

UFH txm ACS/STEMI dose

A

60/unit/kg IV bous, 12 unit/kg/hr inusion

use TBW

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11
Q

UFH monitoring

A

aPPT
Platelets, Hgb, Hct baseline and daily ( dec platelets by 50% possible HIT)

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12
Q

LMWH boxed warnings

A

receiving epidural/spinal anesthesia or spinal puncture due to risk of hematomas and subsequent paralysis

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13
Q

LWMH CI

A

history of HIT
active major bleed

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14
Q

LMWH ppx VTE dosing

A

30mg Q24hr or 40mg Q24hr

30mg Q 24hr if CrCl < 30

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15
Q

LMWH txm VTE, UA and NSTEMI

A

1mg/kg Q12hr
1.5mg/kg QD (in patient VTE only)

1mg/kg Q24hr if CrCl < 30

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16
Q

LMWH txm STEMI in pts < 75yrs of age

A

30mg IV bolus + 1mg/kg dose + 1mg/kg Q12 (max 100mg 1st 2 doses)

CrCl < 30 = 30mg IV bolus + 1mg/kg dose + 1mg/kg Q24hr

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17
Q

LMWH txm STEMI in pts > 75yrs old

A

0.75mg/kg Q12hr

CrCk < 30 = 1mg/kg Q24hrs

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18
Q

LMWH antidote

A

protamine

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19
Q

LMWH monitoring

A

can monitor anti-Xa levels

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20
Q

4Ts score

A

probability of HIT calculated using this score

Thrombocytopenia = unexplained drop of > 50% in platelet count
Timing = HIT onset usually 5-10 days after start heparin
Thrombosis = new suspected/confirmed thrombosis, skin lesions

if HIT is likely, ELISA is done and thats confirmed with a serotonin release assay or heparin-induced platelet aggregation assay

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21
Q

HIT management

A

If suspected or confirmed, stop all heparin/LMWH, if on warfarin then stop and admin Vitamin K.

rapid-acting non-heparin anticoagulant used (argatroban)

Dont restart warfarin until platelets > 150K

if urgent surgery or PCI required, bivalirudin preferred agent

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22
Q

Apixaban nonvalvular AF (stroke ppx) dosing

A

5mg BID

2.5mg BID IF 2 of the following: > 80, < 60kg or SCr < 1.5

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23
Q

Apixaban txm of DVT/PE dosing

A

10mg BID for 7 days, then 5mg BID

Extended phase (after > 3 months txm) - 2.5mg BID

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24
Q

Apixaban ppx DVT (after hip/knee replacement)

A

2.5mg BID (12 days for knee or 35 days for hip)

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25
Q

Edoxaban has reduced efficacy in pts with CrCl that is

A

> 95

26
Q

Apixaban and Rivaroxaban antidote is

A

andexanet alfa (Andexxa)

27
Q

Rivaroxaban should be taken with…

A

food for doses > 15mg

10mg doses can be taken without regard to food

28
Q

Rivaroxaban nonvalvular AF (stroke ppx)

A

CrCl > 50 = 20mg QD w/ evening meal
CrCl 15-50 = 15mg QD w/ evening meal
CrCl < 15 = dont use

29
Q

Rivaroxaban txm fo DVT/PE

A

15mg BID X 21 days, then 20mg QD w/ food
Extended phase (> 3 months) 10mg QD

CrCl < 30 = dont use

30
Q

Rivaroxaban ppx DVT (after knee/hip replacement) and VTE (acute ill medical pts)

A

10mg QD X 12 days (knee), 35 days (hip), 31-39 days (acute ill medical patients)

CrCl < 30 = dont use

31
Q

Rivaroxaban reduction in risk of major CVD events in CAD/PAD

A

2.5mg BID in combo w/ low dose aspirin

CrCl < 15 = avoid use

32
Q

Edoxaban non valvular AF (stroke ppx)

A

CrCl > 95 = dont use
CrCl 51-95 = 60mg QD
CrCl 15-50 = 30mg QD
CrCl < 15 = dont use

33
Q

Edoxaban txm of DVT/PE

A

60mg QD, 5-10 days after parenteral anticoag

IF CrCl 15-50, BW < 60kg, on certain P-gp inhib = 30mg QD

Dont use CrCl < 15

34
Q

Time cut offs for DOAC and surgery

A

Apixaban = stop 48hrs before if mod-high bleeding risk, 24hrs if low

Rivaroxaban/Edoxaban = stop 24hr before

35
Q

Converting from warfarin to other anticoagulant

A

Rivaroxaban when INR < 3
Edoxaban when INR < 2.5
Apixaban when INR < 2
Dabigatran when INR < 2

36
Q

Fondaparinux ppx of VTE

A

> 50kg 2.5 mg QD
< 50 kg = CI

37
Q

Fondaparinux txm of VTE

A

< 50kg = 5mg QD
50 - 100kg = 7.5mg QD
> 100kg = 10mg QD

38
Q

Fondaparinux CrCl cut offs

A

CrCl 30-50 = use caution
CrCl < 30 = CI

39
Q

Dabigatran CI

A

treatment of pts with mechanical prosthetic heart valves

40
Q

Dabigatran Side effects

A

Dyspepsia
Gastritis like symptoms
Gi bleeding

41
Q

Dabigatran antidote

A

idarucizumab (Praxbind)

42
Q

Dabigatran nonvalvular AF (stroke ppx)

A

150mg BID

CrCl 15-30 = 75mg BID
CrCl < 15 = dont use

43
Q

Dabigatran txm of DVT/PE and reduction of recurrent DVT/PE risk

A

150mg BID, start 5-10 days after parenteral anticoag

CrCl < 30 = dont use

44
Q

Dabigatran ppx of DVT/PE following hip replacement

A

110mg Day 1, 220mg QD
CrCl < 30 = avoid use

45
Q

Dabigatran notes

A

have to dispense in OG container, and throw out after 4 months of opening

Swallow capsule whole, dont give in NG tube

46
Q

Argatroban notes

A

Safe for history of HIT or active HIT

No antidote

47
Q

Warfarin CI

A

Pregnancy, unless mechanical heart valve and high risk for TE

48
Q

Warfarin Warnings

A

tissue necrosis/gangrene
HIT
VKORC1 gene or CYP2C9*2/3 allele may inc bleeding

49
Q

Warfarin INR goal for most indications

A

2-3

50
Q

Warfarin INR goal of 2.5-3.5 for….

A

high risk indications such as mechanical mitral valve, 2 mechanical heart valves, or mechanical aortic valve with 1 additional risk factor

51
Q

Warfarin Antidote

A

Vitamin K

Kcentra can be used with vitamin K for rapid reversal

52
Q

Foods high in Vitamin K will do what to INR

A

decrease, so would have to increase warfarin dose (Dark leafy greens)

important to keep consistent vitamin K balance in diet when on warfarin

53
Q

Using Vitamin K for over anticoagulation

A

INR > 4.5 w/o bleeding = reduce or skip dose, monitor INR
INR 4.5 - 10 w/o bleeding = hold 1-2 dose, monitor INR
INR > 10 w/o bleeding = hold warfarin, give Vitamin K
Major bleeding = hold warfarin, give Vitamin K & Kcentra

54
Q

Any VTE caused by surgery or reversible risk factor should be treated for….

A

3 months

55
Q

If VTE is unprovoked, should be treated for….

A

longer than 3 months of low-mod risk of bleeding
keep at 3 months if high

56
Q

If 2 episodes of unprovoked VTE then consider….

A

long term treatment

57
Q

Medications CI in patients with hx of or current VTE

A

estrogen containing medications
selective estrogen receptor modulators

58
Q

pts w/o cancer, dabigatran or DAOC preferred over….

A

warfarin for 1st 3 months of txm for DVT in leg or PE

59
Q

pts w/o cancer, what is preferred over warfarin/LMWH?

A

DOACs

60
Q

CHA2DS2-VASc Score

A

C = CHF
H = HTN
A2 = Age > 75 = 2 pts
D = Diabetes
S2 = Prior stroke/TIA = 2 pts
V = Vascular Disease (prior MI, PAD, aortic plaque)
A = age 65-74 = 1 pt
Sc = Sex, Female = 1 pt

61
Q

HAS-BLED score

A

H = HTN > 160
A = abnormal liver or renal function = 1-2
S = prior stroke
B = Bleeding tendency or predisposition
L = labile INR if on warfarin
E = elderly > 65
D = Drugs (aspirin/NSAIDs) excess alc use = 1-2

62
Q

Anticoagulation in pregnancy

A

LMWH preferred

NAPLEX review 2024 RXPrep Book (78 decks)

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