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NAPLEX > Anticoagulation Dosing > Flashcards

Anticoagulation Dosing Flashcards

1
Q

Heparin: Prophylaxis of VTE:

A

5,000 units SC q8-12H

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2
Q

Heparin: Treatment of VTE

A

80 units/kg IV bolus
18 units/kg/hr infusion

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3
Q

Heparin: Treatment of ACS/STEMI

A

60 units/kg IV bolus
12 units/kg/hr infusion

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4
Q

Heparin antidote

A

protamine

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5
Q

What direct thrombin inhibitor does not cross-react with HIT antibodies?

A

Argatroban

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6
Q

When monitoring Heparin, when should aPTT or anti-Xa level be checked?

A

check 6 hours after initiation and every 6 hours until therapeutic.
-then every 24 hours and with every dose change

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7
Q

aPTT therapeutic range

A

1.5 - 2.5x control (per specific hospital protocol)

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8
Q

Anti-Xa therapeutic range

A

0.3 - 0.7 units/mL

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9
Q

Side effects of heparin

A

-bleeding
-thrombocytopenia
-HIT
-hyperkalemia

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10
Q

1mg of LMWH is equivalent to how many units of anti-Xa activity?

A

100 units

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11
Q

LMWH: Prophylaxis of VTE

A

30mg SC Q12H
40 mg SC daily
*CrCl less than 30 —> 30mg SC QD

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12
Q

LMWH: Treatment of VTE and NSTEMI

A

1 mg/kg SC q12H
1.5mg/kg SC daily (for inpatient VTE treatment)
*CrCL less than 30ml/min: 1 mg/kg SC daily

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13
Q

LMWH: Treatment of STEMI in patients less than 75 years old

A

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

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14
Q

LMWH: Treatment of STEMI in patients greater than 75 years old

A

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)

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15
Q

For dosing both heparin and LMWH, what body weight should be used?

A

Total body weight

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16
Q

Antidote of LMWH

A

protamine

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17
Q

Boxed warning for LMWH

A

-neuraxial anesthesia (epidural,spinal), or spinal puncture
*risk of hematoma or paralysis

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18
Q

Why is anti-Xa level monitoring required in LMWH?

A

it is more predictable than heparin. but anti-Xa levels are recommended in pregnant patients.
aPTT IS NOT USED!!!!

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19
Q

What are the components of the 4Ts score to find the probability of HIT?

A

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

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20
Q

If a patient has HIT but needs an urgent PCI what should be given?

A

Bivalirudin

21
Q

What most platelets recover to in a patient with HIT before starting warfarin?

A

-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

22
Q

Apixaban: Nonvavlular AF

A

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

23
Q

Apixaban: treatment of DVT/PE

A

10 mg BID x 7 days then 5 mg BID
if more than 3 months drop to 2.5mg BID

24
Q

Eliquis: Prophylaxis for DVT post hip or knee replacement

A

2.5mg BID for 12 days post knee and 35 days post hip
*first dose 12 to 24 hours after surgery

25
Q

Does Xarelto need to be taken with food?

A

Yes, doses of 15mg or greater must be taken with a meal (usually evening meal)

26
Q

Rivaroxaban: nonvalvular AF

A

CrCl > 50: 20mg with evening meal
CrCl 15-15: 15mg with evening meal
CrCl <15: avoid use

27
Q

Rivaroxaban DVT/PE treatment

A

Initial: 15 mg BID x 21 days then 20 mg daily with food
(if greater than 3 months, go down to 10mg daily)
CrCl <30: avoid use

28
Q

Rivaroxaban: Prophylaxis for DVT (knee/hip) and VTE in acutely ill

A

10mg daily x 12 days (knee) and x 35 days (hip), 31 -39 days acutely ill)
*first dose 6-10 hours after surgery
CrCl <30: avoid use

29
Q

Black box warning specifically for edoxaban?

A

Reduced efficacy in patients with CrCl greater than 95

30
Q

Black boxed warning for the DOACS

A

neuraxial anesthesia (epidural, spinal, spinal puncture) at risk for hematomas and paralysis
-premature discontinuation increases risk of thrombotic events

31
Q

Edoxaban: Nonvalvular AF

A

CrCl>95: avoid -black box
CrCl: 51-95: 60mg daily
CrCl: 15-50: 30mg daily
CrCl: <15: avoid

32
Q

Edoxaban: treatment of DVT/PE

A

60 mg daily after 5-10 days of IV anticoagulation
*If CrCl: 15-50, body weight less than 60 kgm or taking certain P-gp inhibitors, then 30mg daily

CrCl < 15: avoid

33
Q

Antidote for DOACS

A

andexanet alfa (Andexxa) but only for Eliquis and Xarelto!

34
Q

Major Contraindication to fondaparinux (Arixtra)

A

severe renal impairment with CrCl less than 30 ml/min

35
Q

Examples of strong dual CYP3A4 and p-gp inducers

A

Carbamazepine
phenytoin
rifampin
St. John’s wart

36
Q

Strong dual inhibitors of CYP3A4 and P-gp

A

Clarithromycin
itraconazole
ketoconazole
ritonavir

37
Q

What are eliquis and Xarelto major substrates for?

A

CYP3A4 and p-gp

38
Q

Converting from warfarin to another oral anticoagulant

A

Rivaroxaban when INR is < 3
Edoxaban when INR 2.5 or less
Apixaban when INR is <2
Dabigatran when INR is <2
READ

39
Q

Converting from a DOAC to warfarin

A

Stop DOAC
Start parenteral anticoagulant and warfarin at next scheduled dose
Refer to edoxaban package insert for conversion

40
Q

Converting from dabigatran to warfarin

A

Start warfarin 1-3 days before stopping dabigatran (determined by renal function)

41
Q

Dabigatran: Treatment of DVT/PE and reduction of risk of recurrent VTEs

A

150 mg BID, starting after 5 - 10 days of parenteral anticoagulation
CrCl < 30: avoid

42
Q

Side effects of dabigatran

A

-dyspepsia
-gastritis symptoms
-bleeding (including GI)

43
Q

Antidote of Pradaxa

A

Antidote = idarucizumab (Praxbind)

44
Q

Modifiable risk factors of VTE

A

Acute medical illness
Immobility
Medications (SERMs)
-drugs containing estrogen, erythropoiesis-stimulating agents

obesity (BMI > 30)
pregnancy and postpartum
recent surgery or trauma

45
Q

Non-modifiable risk factors of VTE

A

Increasing age
cancer/ chemotherapy
Previous VTE
Inherited/acquired thrombophilia:
AT deficiency, factor V Leiden antiphospholipid syndrome, protein C or S deficiency)
Certain disease states (heart failure, nephrotic syndrome, respiratory failure

46
Q

Preferred method of VTE treatment in cancer patients

A

DOACs preferred

47
Q

What does CHA2DS2-VASC Scoring System stand for and what does each letter represent

A

Scoring tool for stroke risk

All worth one point unless 2 in name
C- CHF
H- HTN
A2- Age 75 or older
D- Diabetes
S2- Prior stroke/ TIA
V- Vascular disease (MI,PAD, Aortic plaque)
A- Age 65-74
Sc- Sex category of female

48
Q

Point interpretation of CHA2DS2-VASc score

A

0-1: Low (no medication required)

1 or more (men): moderate (Consider Med)
2 or more (female)

2 or more (Men)
3 or more (female): oral med recommended (DOACs preferred over warfarin)

49
Q

What is the HAS-BLED Scoring system and what does it stand for?

A

-assesses bleeding risk in patient requiring anticoagulation for stroke prevention
-higher the score the greater the risk of bleeding

H- HTN (SBP > 160 mmHg)……..1
A- abnormal liver/kidney function…….1-2
S- Prior Stroke………………..1
B-Bleeding predisposition……………1
L- Labile INR on warfarin………..1
E- Elderly (over 65) ………………….1
D- Drugs (ASA, NSAIDs), alcohol use….1-2

NAPLEX (7 decks)

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