Bleeding Management and Antidotes

Question 1

What is the antidote used to reverse UFH and LMWH?

Answer 1

Protamine Sulfate

Question 2

What is the antidote used to reverse dabigatran?

Answer 2

Idarucizumab

Question 3

What is the antidote used to reverse factor Xa inhibitors?

Answer 3

Andexanet alfa

Question 4

How is protamine sulfate dosed for patients overdosing on LMWH?

Answer 4

-It is dosed based on the amount of anti-factor Xa in the body or, if enoxaparin was used, then it is dosed based on the amount of enoxaparin given
-If given within 8 hours of last dose then use 1mg but if given longer than 8 hours since the last dose then use 0.5mg

Question 5

Possible adverse reactions associated with protamine sulfate

Answer 5

-Hypotension
-Bradycardia
-Treat by slowing down the infusion

Question 6

How is protamine sulfate dosed for patients overdosing on UFH?

Answer 6

-Dose based on how much UFH was given over the past 3 hours
-1 mg protamine/100 units UFH given over the past 3 hours

Question 7

How does idarucizumab work?

Answer 7

Directly binds to dabigatran because it has a higher affinity for dabigatran than thrombin does

Question 8

How is idarucizumab given?

Answer 8

2 separate 2.5 g IV doses no more than 15 minutes apart

Question 9

How do you monitor idarucizumab?

Answer 9

-Monitor aPTT when idarucizumab is first given
-Repeat test in 2 hours
-Test aPTT every 12 hours until it is normal

Question 10

How does andexanet alfa work?

Answer 10

Binds and sequesters FXa inhibitors (rivaroxaban and apixaban)

Question 11

When do you give a low dose of andexanet alfa?

Answer 11

-If the patient took 5 mg or less of apixaban
-If the patient took 10 mg or less of rivaroxaban
-If the patient took their last dose of the FXa inhibitor 8 hours or more ago

Question 12

When do you give a high dose of andexanet alfa?

Answer 12

-If the patient took more than 5 mg or an unknown amount of apixaban AND it was taken less than 8 hours ago or the time it was taken is unknown
-If the patient took more than 10 mg or an unknown amount of rivaroxaban AND it was taken less than 8 hours ago or the time it was taken is unknown

Question 13

What do you give to reverse warfarin?

Answer 13

-Vitamin K
-Fresh Frozen Plasma
-Prothrombin Complex Concentrate

Question 14

How do you treat someone on warfarin who has an INR of 4.5-10 and NO evidence of bleeding?

Answer 14

Avoid vitamin K

Question 15

How do you treat someone on warfarin who has an INR greater than 10 and NO evidence of bleeding?

Answer 15

PO vitamin K

Question 16

How do you treat someone who has major bleeding while on warfarin?

Answer 16

Prothrombin complex concentrate

Question 17

Why is PCC preferred over fresh frozen plasma?

Answer 17

PCC works rapidly and fully reverses warfarin