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Cardio Therapeutics > Anticoagulation I > Flashcards

Anticoagulation I Flashcards

1
Q

Signs and Sx of DVT and PE

A

DVT
-Unilateral leg swelling (warmth, tender, discoloration)
-Pain behind knee/calf when flexing foot (+ Homan’s)
-Palpable cord

PE
-Dyspnea
-Tachycardia/tachypnea
-Chest pain/tightness

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2
Q

Diagnosis of DVT and PE

A

DVT
-US (+ dopple/b mode)
-Dimer 240+ (elevated)
-Wells score 2+

PE
-V/Q scan (+)
-Spiral CT
-Dimer 240+
-Wells PE score >4

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3
Q

Wells Score: DVT and PE

A

DVT
-Low: =< 0
-Mod: 1-2
-High: >= 3

PE
-Likely: > 4
-Unlikely: =< 4

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4
Q

General Approach: Treatment of VTE

A
  1. Cardiopulmonary compromise or high risk of limb loss = FIBrinolytic + UFH/LMWH
  2. Active bleeding or CI and lower extremity = IVC filter, initiate AC when cleared
  3. Poor prognosis/can’t tx output = hospitalize
    -CrCl < 30 = UFH x 5 overlap warfarin
    -CrCl 30+ = UFH x 5 overlap warfarin or UFH with DOAC transition OR vvv
  4. Outpt tx = Riva/Apix/LMWH with fonda x 5 then dab/edox or LMWH x 5 overlap warfarin (RALF DWEL)
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5
Q

Risk Factors for Major Bleeding While Taking Anticoagulation Therapy

A

-65+
-NSAID use
-Hx of GI bleed
-Recent surgery/trauma
-Heavy alcohol use
-Renal failure
-Malignancy
-Initiation of tx

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6
Q

Fibrinolytic Drugs Potential
-Alteplase (t-PA)
-Tenecteplase (TNK)
-Streptokinase
-Urokinase

A

Potential to dissolve not only pathologic thrombi but physiologically appropriate fibrin clots
– could lead to hemorrhage of varying severity

*bc not site specific

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7
Q

Fibrinolytic Drugs: Indications/CI

A

Indications
1) Massive ileo-femoral DVT at risk for limb gangrene due to venous occlusion
2) Hemodynamically unstable PE patients (ie. SBP < 90, shock)

CI
-Active bleeding, hemorrhage hx
-Ischemic stroke within 3 months
-Cancer/vascular lesion
-Aortic dissection
-Trauma/surgery (head)
-Severe uncon HTN
(BIHH VCAT)

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8
Q

Fibrinolytic Drugs: Dosing

A

Before fibrinolytic therapy begins, administer IV heparin in full therapeutic doses (then suspend during fib tx)

Altepase
-PE: 100 mg IV infusion over 2 hours x 1 dose
-Cardiac arrest: 50 mg IV bolus x 1 dose

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9
Q

Initial Acute Phase Treatment

A

Rapid-acting (FULAR)
-UFH (IV/SC)
-SC LMWH
-SC Fondaparinux
-Oral rivaroxaban or apixaban

-Dab/edox not used bc need 5-10 days of parenteral tx first

Transition from parenteral therapy to orals:
–5 days and until INR 2-3 for at least 24 hr, then continue on PO warfarin alone = BEST PRACTICE
– No overlap is necessary if switching from parenteral therapy to rapid acting DOAC (rivaroxaban or apixaban)

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10
Q

Heparin: Monitoring

A

PREFERRED IN RENALLY IMPAIRED PTS = not renally excreted

Baseline Labs
* CBC with platelets
* PT/INR
* aPTT
* BUN
* Serum creatinine

Ongoing Labs
* aPTT or anti-Xa
– 6 hours after initial bolus
– every 6 hours until 2 consecutive aPTT / anti-Xa values are therapeutic, then daily
* CBC with platelets
– Daily if pretx < 100,000
– Every 72 hours if > 100,000

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11
Q

Heparin: Dosing

A

IV: 80 u/kg (max 10,000) followed by 18 u/k/hr (max rate 2,150 u/hr)

  • goal aPTT 50-77 seconds
  • goal anti-Xa 0.3-0.7 IU/mL
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12
Q

Heparin: Precautions and Side Effects

A

-Narrow therapeutic window
-Heparin induced thrombocytopenia
-Hemorrhage

-Hypersensitivity rxn
-Hyperkalemia
-Osteoporosis

(HHHHON)

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13
Q

LMWH: Enoxaparin/Dalteparin
Dosing/Monitoring

A

Enoxaparin

1mg/kg SC BID or 1.5-2.0 mg/kg SC daily

*renal adj req for both

Higher risk patients that may require monitoring: CCEO at 30
– obese pts
– renal, CrCl <30
– elderly/children
– cancer

Use anti-factor Xa
- labs: hemoglobin, hematocrit, platelet count

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14
Q

Heparin Induced Thrombocytopenia

A
  1. Platelet count drop of 50% from baseline
  2. Venous or arterial thrombosis
  3. Skin lesions at heparin injection sites
  4. Acute systemic reactions that occur after a bolus of IV heparin

*Prompt DC of ALL heparin products
-Initiation of argatroban/bivalirudin (ICU) or fondaparinux (= if stable) as alt
-Platelet count usually recovers in 4-7 days

4 Ts (thrombocyto/time/thrombosis/other)
- ≤3: low for HIT
– 4-5: intermediate
– 6-8: high for HIT

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15
Q

Fondaparinux (Arixtra®)

A
  • < 50 kg: 5 mg SC daily
  • 50-100 kg: 7.5 mg SC daily
  • > 100 kg: 10 mg SC daily

CLcr < 30 mL/min: CONTRAINDICATED

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16
Q

Bivalirudin: DTI

A

Indications: CHC
– as alternative to heparin when undergoing coronary angioplasty or CABG
– as alternative to heparin in HIT

*renal adj

Normal dose: 0.15 mg/kg/hr

17
Q

Argatroban: DTI

A

Used as alternative to heparin in patients with or at risk of developing HIT

*hepatic adj

Normal dose: 2 mcg/kg/min IV

ARG the pirate’s liver is 2 HIT

18
Q

Dabigatran: DOAC

A

ONLY (dabi is 30 but acts 150, GRH she’s a B)
-Requires UFH/LMWH/Fonda beforehand
-CLcr > 30 after 5- 10 days of parenteral therapy:
= 150 mg PO BID

CLcr ≤ 30 mL/min: NO

For CLcr < 50 mL/min with concomitant use of P-gp inhibitors: avoid co- administration

AE:
-Bleeding, GI distress, rash, hives

19
Q

Rivaroxaban: DOAC

A

ONLY (BOB goes down the river at 15 15 x2 x21 20)
CLcr ≥ 15 mL/min:
15 mg PO BID x 21 days then 20 mg PO qPM

CLcr < 15 mL/min: NO

To reduce risk of recurrence:
CLcr > 15 mL/min: 10 mg PO daily after at least 6 mo

AE:
-Bleeding, back pain, osteoarthritis

20
Q

Apixaban: DOAC

A

10 mg PO BID x 7 days, then 5 mg PO BID thereafter

Reduce recurrence:
2.5 mg PO BID after at least 6 months of standard dosing

AE: bleeding

21
Q

Edoxaban: DOAC

A

CLcr > 50 and after 5-10 days of parenteral therapy:
-Weight > 60 kg: 60 mg PO daily

For CLcr 15-50 mL/min or weight ≤ 60 kg or who use certain P-gp inhibitors1: 30 mg PO daily

CLcr < 15 mL/min: NO

AE: bleeding

22
Q

Pt Education for DOAC’s

A

-Do not abruptly stop taking your blood thinner (risk of thrombotic events)
-Report any bleeding (unexpected/lasts long/uncontrolled)
-May have higher risk of bleeding if you take aspirin, NSAIDs, warfarin

*Rivaroxaban with evening meal
*Dabigatran: use within 4 mo of opening bottle, keep capsules in original bottle at RT

23
Q

Warfarin: Monitoring

A

INR: 2-3
*2.5-3.5 for high-risk mechanical prosthetic heart valves

Get baseline labs (PT/INR, CBC, liver panel, albumin)

70+
-AA: 7.5
-CH: 5
-As: 2.5

=<70
-AA: 5
-CH: F 2.5, M 5
-As: 2.5

24
Q

Warfarin: Drugs and Herbal Interactions

A

SAM CAP

-Pheny/Pheno
-Amiodarone
-Carb/cim/cipro
-Mycin
-Azoles
-SJW/sulf

24
Q

Warfarin: Raising/Lowering Factors

A

Reduce starting dose by 2.5 mg or 50% (whichever is less) or increase starting dose by 2.5 mg or 50% (whichever is less)

Dose Lowering Factors
* Weight < 45 kg
* Baseline INR > 1.3
* Malnourishment
* Albumin < 3
* Liver disease
* Catabolic conditions (recent surgery, hyperthyroidism, ADHF, pneumonia)
* Taking azole antifungals, metronidazole, Septra, amiodarone

Dose Raising Factors
* Weight > 90 kg
* Untreated hypothyroidism
* Receiving enteral feeds
* Taking rifampin, carbamazepine, dicloxacillin, phenobarbital, bosentan

25
Q

Warfarin: Toxicities

A

-Bleeding
-Birth defects (Cat X/D)
-Skin necrosis
-Purple toe

26
Q

Warfarin: Patient Education

A

-Never skip a dose or take a double dose
-INR is the blood test used to determine how thin your blood is, will get it checked regularly
-Too much = bleeding, too little = clots
-AE: bleeding, bruising
-If you sustain an injury or fall OR you hit your head at any time, seek medical attention
-Food can affect it (green leafy veg) = keep diet consistent
-Alcohol limit 1 d/d

27
Q

Transitioning to Warfarin

A
  • When treating DVT/PE, overlap UFH/LMWH treatment with warfarin
    – Must treat with both for at least 5 days
    – Must have therapeutic INR for 2 consecutive days
28
Q

Protamine sulfate

A

Reverses Heparin

  • 1 mg protamine : 100 units circulating heparin
  • t 1⁄2 60 minutes
  • Administration: slow IV push over 1-3 minutes
  • No more than 50 mg should be administered in a 10-minute period

– 1 mg protamine : 1 mg enoxaparin (if enox. given < 8 hours ago)
– 0.5 mg protamine : 1 mg enoxaparin (if enox. given > 8 hours ago)

AE:
– Dyspnea, wheezing, cyanosis
– Flushing, urticaria
– Chills
– Chest pain
– Nausea / vomiting
– Bradycardia, hypotension, anaphylactoid rxn

29
Q

Vitamin K

A

PO preferred

reverse the effects of warfarin

30
Q

4-factor prothrombin complex concentrates (KcentraTM)

A

Must be given with Vitamin K

31
Q

Idarucizumab (PraxbindTM)

A

Only for dabigatran

FOR
1. emergency surgery / urgent surgical procedures
2. life-threatening or uncontrolled bleeding

DOSE: 2.5g/50mL IV bolus x 2 (total dose=5g)

RISK: possible thromboembolic complications

32
Q

Andexanet Alfa (AndexXaTM)

A
  • INDICATION:
    – indicated for patients treated with rivaroxaban or apixaban, when reversal of anticoagulation is needed due to life-threatening or uncontrolled bleeding

RISK: possible thromboembolic complications

33
Q

Fresh Frozen Plasma (FFP)

A
  • 10-20 mL/kg will increase factor levels by 20-30%
  • 1-unit FFP = 200 mL

Cardio Therapeutics (31 decks)

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