Anticoagulation Dosing Flashcards
(49 cards)
Heparin: Prophylaxis of VTE:
5,000 units SC q8-12H
Heparin: Treatment of VTE
80 units/kg IV bolus
18 units/kg/hr infusion
Heparin: Treatment of ACS/STEMI
60 units/kg IV bolus
12 units/kg/hr infusion
Heparin antidote
protamine
What direct thrombin inhibitor does not cross-react with HIT antibodies?
Argatroban
When monitoring Heparin, when should aPTT or anti-Xa level be checked?
check 6 hours after initiation and every 6 hours until therapeutic.
-then every 24 hours and with every dose change
aPTT therapeutic range
1.5 - 2.5x control (per specific hospital protocol)
Anti-Xa therapeutic range
0.3 - 0.7 units/mL
Side effects of heparin
-bleeding
-thrombocytopenia
-HIT
-hyperkalemia
1mg of LMWH is equivalent to how many units of anti-Xa activity?
100 units
LMWH: Prophylaxis of VTE
30mg SC Q12H
40 mg SC daily
*CrCl less than 30 —> 30mg SC QD
LMWH: Treatment of VTE and NSTEMI
1 mg/kg SC q12H
1.5mg/kg SC daily (for inpatient VTE treatment)
*CrCL less than 30ml/min: 1 mg/kg SC daily
LMWH: Treatment of STEMI in patients less than 75 years old
30 mg IV bolus + 1mg/kg SC dose
followed by 1mg/kg SC q12h (max 100mg for first two SC doses only)
*CrCl less than 30 ml/min: 30mg IV bolus + 1mg/kg SC dose followed by 1mg/kg SC daily
LMWH: Treatment of STEMI in patients greater than 75 years old
No bolus! Just 0.75 mg/kg SC q12h (no bolus - max 75mg for the first two SC doses only)
*CrCL less than 30 ml/min: 1mg/kg SC daily (no bolus)
For dosing both heparin and LMWH, what body weight should be used?
Total body weight
Antidote of LMWH
protamine
Boxed warning for LMWH
-neuraxial anesthesia (epidural,spinal), or spinal puncture
*risk of hematoma or paralysis
Why is anti-Xa level monitoring required in LMWH?
it is more predictable than heparin. but anti-Xa levels are recommended in pregnant patients.
aPTT IS NOT USED!!!!
What are the components of the 4Ts score to find the probability of HIT?
Thrombocytopenia: drop greater than 50% in platelet count from baseline
Timing: 5 to 10 days after the start of heparin or hours if pt was exposed in the last 3 months
Thrombosis: new or skin lesions that are necrotizing or not
inability to identify another cause or inability to rule out HIT
If a patient has HIT but needs an urgent PCI what should be given?
Bivalirudin
What most platelets recover to in a patient with HIT before starting warfarin?
-do not start warfarin therapy unless platelets recover (>150,000 cells/mm3)
-initiate at 5mg max
-overlap with non-heparin anticoagulant for 5 days until INR in target range for 24 hours
Apixaban: Nonvavlular AF
5mg BID
**If they have 2 of the following: then 2.5mg BID
-80 or older
-body weight 60 kg or less
-SCr 1.5 or greater
Apixaban: treatment of DVT/PE
10 mg BID x 7 days then 5 mg BID
if more than 3 months drop to 2.5mg BID
Eliquis: Prophylaxis for DVT post hip or knee replacement
2.5mg BID for 12 days post knee and 35 days post hip
*first dose 12 to 24 hours after surgery