Anticoagulation in special populations

Question 1

What populations would need special consideration if they are to receive anticoagulation

Answer 1

Pregnancy, Renal insufficiency, Extremes of body weight, Patients with cancer

Question 2

What are indications that would put a pregnant women on anticoagulants

Answer 2

Prophylaxis against VTE and arterial thrombosis, Treatment of thrombosis during pregnancy, prevention of pregnancy loss

Question 3

What are high risk circumstances that would lead a women to be advised to not get pregnant

Answer 3

mechanical heart valves, chronic thromembolic pulmonary hypertension, history of recurrent thrombosis while fully anticoagulated, history of MI

Question 4

T/F: If a patient is on anticoagulants before pregnancy they will need to be on some type of anticoagulant during pregnancy

Answer 4

True

Question 5

What is the best anticoag to give to a pregnant patient

Answer 5

LMWH

Question 6

T/F: If a patient is on anticoagulants they should also be off estrogen containing birth control because their risk for clot is increased

Answer 6

False: If a patient is on anticoagulants they can’t be on combined estrogen birth controls

Question 7

When is LMWH the best option for pregnant patients, What other times during pregnancy is LMWH acceptable

Answer 7

First trimester, during late pregnancy when delivery is imminent, second and third trimesters

Question 8

When is Heparin better for pregnant patients

Answer 8

Patient has severe renal dysfunction

Question 9

When would fondaparinux be better for patients

Answer 9

Allergies to LMWH/Heparin or history of heparin induced thrombocytopenia

Question 10

What are the prophylacitic LMWH doses for pregnant women, intermediate dose LMWH

Answer 10

Dalteparin 5000 units SC every 24 hours, Enoxaparin 40 mg SC every 24 hours/ Dalterparin 5000 units SC every 12 hours, Enoxaparin 40 mg SC every 12 hours

Question 11

How long should postpartum anticoagulation be

Answer 11

At least 6 weeks

Question 12

T/F: Aspirin crosses the placenta and should only be used in 81 mg tablets and to treat preclampsia but should be avoided in the last week

Answer 12

True

Question 13

When is warfarin the most dangerous for a fetus

Answer 13

First 6-12 weeks

Question 14

When is the ONLY circumstance a pregnant patient would be given warfarin, what dose must it be

Answer 14

Patient has a mechanical heart valve, less than 5 mg

Question 15

T/F: If a patient is receiving anesthesia than their anticoagulant should be stopped immediately

Answer 15

True

Question 16

What are the safe anticoagulant options for breastfeeding

Answer 16

Warfarin, Heparin, LMWH

Question 17

What kidney monitoring parameter is associated with a higher risk of bleeding, what is the value

Answer 17

Scr, greater than 1.5 mg/dl

Question 18

What other heart condition becomes more likely with worsening kidney function

Answer 18

Atrial fibrillation

Question 19

Rank the renal elimination of the LMWHs and Heparin from most renally eliminated to least renally eliminated, what anticoagulant can NEVER be used in a patient with bad renal function and why

Answer 19

Enoxaparin, Dalteparin, Tinzaparin, Heparin/Fondaparinux, excreted 100% through the urine

Question 20

T/F: Caution in using LMWH becomes apparent at a CrCl of less than or equal to 50

Answer 20

False: Caution in using LMWH becomes apparent at a CrCl of less than or equal to 30

Question 21

What is the enoxaparin prophylaxis dose for a patient with a CrCl less than 30, treatment

Answer 21

30 mg SC daily, 1 mg/kg SC daily

Question 22

What is the best anticoagulant to give someone with renal insufficiency, why

Answer 22

Heparin, eliminated by the liver

Question 23

What is monitored for efficacy in warfarin, Heparin, LMWH

Answer 23

INR, aPTT, Anti-Factor Xa

Question 24

What is monitored for safety in warfarin, Heparin, LMWH and DOACs

Answer 24

INR, CBC, LFTs/ Platelet count/ Anti-factor Xa, Platelet count, Scr/ Scr and CBCs

Question 25

Which DOAC is most reliant on renal elimination, which is not

Answer 25

Dabigatran, Apixiban

Question 26

T/F: DOACs are safe to use in ESRD

Answer 26

False: DOACs are contraindicated in ESRD as they cause a higher risk of bleeding

Question 27

Which DOAC should not be used if the CrCl is greater than 95

Answer 27

Edoxaban

Question 28

What is the best DOAC to give if a patient is on dialysis

Answer 28

Apixiban

Question 29

What are the best ANTICOAGULANT choices for patients with renal clearance less than 30

Answer 29

Heparin, Warfarin, Argatroban, Apixaban

Question 30

When someone is at extremes of body weight how is dosing done in Heparin and LMWH

Answer 30

Use total body weight

Question 31

T/F: Warfarin can be given no matter the weight therefore it is the best option

Answer 31

True

Question 32

T/F: There are no recommendations for changing the dose for DOACs

Answer 32

True

Question 33

What are the two DOACs that can be used in cancer patients with VTE, what is the risk

Answer 33

Edoxaban and Rivaroxaban, increased risk of bleeding with lower risk of clotting

Question 34

What are the treatment options for treating cancer patients with a high risk of bleeding, low risk of bleeding

Answer 34

LMWH, Edoxaban or Rivaroxaban

Question 35

What anticoagulants can be used regardless of kidney function

Answer 35

Warfarin and Heparin

Question 36

What is the weight cap for using DOACs

Answer 36

120 kg