Chapter 34: Anticoagulation

Question 1

Heparin Dosing: Prophylaxis of VTE

Answer 1

5,000u subq q8-12h

Question 2

Heparin Dosing: Treatment of VTE

Answer 2

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

Use total body weight for dosing

Question 3

Heparin Dosing: Treatment of ACS/STEMI

Answer 3

60 u/kg IV bolus (max 4,000u)
Then 12 u/kg/hr (max 1,000u)
Use total body weight for dosing

Question 4

Enoxaparin Dosing: Prophylaxis of VTE

Answer 4

30mg subq q12h
or
40mg subq qd

CrCl <30: 30mg subq qd

Question 5

Enoxaparin Dosing: Treatment of VTE and UA/NSTEMI

Answer 5

1 mg/kg subq q12h
or
1.5 mg/kg subq qd (only for inpatient vte tx)

CrCl <30: 1 mg/kg subq qd

Use total body weight for dosing

Question 6

Enoxaparin Dosing: Treatment of STEMI

Answer 6

Patients <75 years 30mg IV bolus plus 1mg/kg subq dose followed by 1mg/kg q12h

CrCl<30; 30mg IV bolus plus 1mg/kg subq dose followed by 1mg.kg qd

Patients >=75: 0.75mg/kg subq q12h (no bolus)

CrCl<30 and >=75 years; 1mg/kg subq qd (no bolus)

Question 7

Heparin and Lovenox Antidote

Answer 7

Protamine
1mg will reverse about 100u of heparin
1mg will reverse 1mg of enoxaparin (only enoxaparin given in previous 8 hours)

Question 8

Edoxaban CI

Answer 8

Savaysa

Do not use is CrCl >95

Question 9

Apixaban and Rivaroxaban Antidote

Answer 9

AndeXAnet Alfa (andexXA)

Question 10

Conversion from Warfarin to other anticoagulant

Answer 10

READ

Rivaroxaban when INR is <3
Edoxaban when INR is <= 2.5
Apixaban when INR is <2
Dabigatran when INR is <2

Question 11

Warfarin Colors and Doses

Answer 11

“Please Let Greg Brown Bring Peaches To Your Wedding”

Pink (1mg)
Lavender (2mg)
Green (2.5mg)
Brown (3mg)
Blue (4mg)
Peach (5mg)
Teal (6mg)
Yellow (7.5mg)
White (10mg)

Question 12

CYP 2C9 inducers

Answer 12

Can decrease INR
Rifampin
Carbamazepine
Phenobarbitol
Phenytoin
Primidone
St. John's Wort

Question 13

CYP 2C9 inhibitors

Answer 13

Can increase INR
amiodarone
azoles
metronidazole
SMX/TMP

Question 14

Foods High in Vitamin K

Answer 14

Spinach
Broccoli
Brussel sprouts
Cabbage
Beef liver
Kale

Question 15

Dabigatran Reversal Agent

Answer 15

Idarucizumab (Praxbind)

Question 16

Warfarin Reversal Agent

Answer 16

Phytonadione (vitamin k)

administer four factor prothrombin complex concentrate (kcentra) with it

Question 17

CHA2DS2-VASc

Answer 17

C-CHF: 1
H-HTN: 1
A-age>=75 years: 2
D-diabetes: 1
S- prior stroke: 2

V-vascular disease: 1
(prior MI, PAD, aortic plaque)
A-age 65-74 years: 1
S-sex: female: 1

Question 18

ChadsVasc Score Recommended Therapy

Answer 18

Score 0 (males) and 1 (females): no anticoag
Score >=1 (males and >=2 (females): po anticoag may be considered
Score >=2 (males) and >=3 (females): po anticoag recommended (DOAC over warfarin)