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CACP > DOACS > Flashcards

DOACS Flashcards

1
Q

What is the Apixaban (eliquis) drug class?

A

Factor Xa inhibitor

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2
Q

what is the % bioavailability of Apixaban (eliquis)?

A

60%

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3
Q

what is the team to peak effect of Apixaban (eliquis)?

A

1-2 hours

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4
Q

what is the 1/2 life of Apixaban (eliquis)?

A

12 hours

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5
Q

what % of Apixaban (eliquis) is renally cleared?

A

25%

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6
Q

what is Dabigatran (Pradaxa) drug class?

A

Direct Thrombin Inhibitor

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7
Q

is Dabigatran (Pradaxa) a prodrug?

A

YES

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8
Q

what is the % bioavailablity of Dabigatran (Pradaxa)?

A

6%

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9
Q

what is the time to peak effect of Dabigatran (Pradaxa)?

A

1-3 hours

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10
Q

what is the 1/2 life of Dabigatran (Pradaxa)

A

8-15 hours

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11
Q

what is the drug class of Edoxaban (Savaysa)?

A

Factor Xa inhibitor

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12
Q

what is the bioavalibity of Edoxaban (Savaysa)?

A

62%

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13
Q

what is the time to peak effect of Edoxaban (Savaysa)?

A

1-2 hours

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14
Q

what % of Edoxaban (Savaysa) is renally cleared?

A

50%

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15
Q

What class of drug is Rivaroxaban (Xarelto)?

A

Factor Xa inhibitor

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16
Q

what is the bioavailablity of Rivaroxaban (Xarelto)?

A

60-80%

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17
Q

what is the time to peak effect of Rivaroxaban (Xarelto)?

A

2-4 hours

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18
Q

what is the 1/2 life of Rivaroxaban (Xarelto)?

A

7-11 hours

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19
Q

what % of Rivaroxaban (Xarelto) is renally cleared?

A

33%

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20
Q

what are the 6 CI for Apixaban?

A
  1. active pathological bleeding
  2. server hypersensivity
  3. mech prosthetic heart valve
  4. Triple postiive APS
  5. pregnancy
  6. breastfeeding (secrection into milk)
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21
Q

what are the 3 DOAC that are clinically recommended to be avoided in pregancy?

A

Dabi
edoxa
riva

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22
Q

which DOAC does not need to be adjusted for hepatic impairment?

A

Dabigatran

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23
Q

which 2 DOACs are eliminated by P-GP efflux transporter system?

A

Dabi

Edoxaban

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24
Q

which 2 DOACS are eliminated/metabolized by P-GP efflux transporter system AND CYP3A4 hepatic isoenzyme system

A

Rivaroxaban

apixaban

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25
Q

what are the 5 examples of P-GP and/or STRONG CYP3A4 inducers

A
  1. barbiturates
  2. carbamazepine
  3. pheytoin
  4. rifampin
  5. St. Johns wort
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26
Q

what DOAC can be use if pt has p-GP and or STRONG CYP 3A4 inducers

A

NONE- it decreases the availablity of the DOACS increase risk of thrombosis

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27
Q

what are the P-GP inhibitors? (8 classes/drug)

A
  1. amiodarone
  2. carvedilol
  3. diltizem
  4. dronaderone
  5. azithro/clarithro/erythromycin
  6. itra/ketoconazole
  7. quinidine
  8. verapamil
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28
Q

which DOACs are not affected by p-GP inhibitors

A

Apixaban and Rivaroxaban

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29
Q

what are the dual P-GP annd STRONG CYP3A4 inhibitors?

A 
Clarithromycin 
itra/ketocontazole
cobicistat
indinavir
ritonavir
saquinavir 
telprevir
30
Q

when using dual P-GP annd STRONG CYP3A4 and APIXBAN - how much do you reduced dose

A

50% if on 5mg BID or 10mg BID
dont use if on 2.5mg
(DONT NEED TO REDUCE IF ITS CLARITHROMYCIN)

31
Q

what is Apixaban dose for AFIB?

A

5mg BID

2.5mg BID (if 2 / 3 criteria weight , 60kg, age >80, Scr >1.5)

32
Q

what is the DABI dose for AFIB and renal dose adjustments?

A

150mg BID

<15ml/min - DONT USE
15-30ml/min: 75mg BID

33
Q

what is the dose for edoxaban for AFIB and any renal dose adjustments?

A

60mg daily

Crcl > 95ml/min: DONT USE
15-50ml/min: 30mg daily

34
Q

what is the dose of rivaroxaban for AFIB? and renal dose adjustements

A

20mg daily

CrCL <50 ml/min = 15mg daily

35
Q

what is the dose of apixaban for VTE

A

10mg BID x 7 days then 5mg BID

NO RENAL DOSE ADJUSTMENT

36
Q

what is the dose of dabi for VTE and the renal adjustment

A

150mg BID AFTER 5-10 days of parentreral lead in

NO DOSE adjust (avoid only if CrCL <30ml/min

37
Q

what is the dose of edoxaban for the treatment of VTE?

A

60mg daily after 5-10 day of parenteral lead in.

15-50ml/min or bodyweight <60kg = 30mg daily

38
Q

what is the dose of rivaroxaban for VTE

A

15mg BID x 21 days then 20mg daily

AVOID if CrCL <30ml/min

39
Q

what is the PPX dose for DVT/PE S/p hip or knee replacement procedure for APixaban?

A
  1. 5mg BID for 12 days (KNEE)
  2. 5mg BID for 36 days (HIP)

give 1st dose 12-24 hours after surgery

40
Q

what is the PPX dose for DVT/PE S/p hip or knee replacement procedure for Dabi?

A

ONLY HIP not FDA approved for KNEE

110mg day 1 then 220mg daily for 28-35 days

41
Q

what is the PPX dose for DVT/PE S/p hip or knee replacement procedure for Edoxaban

A

NOT CLEARED for this

42
Q

what is the PPX dose for DVT/PE S/p hip or knee replacement procedure for Rivaroxban?

A

10mg daily for 12 days (knee)

10mg daily for 35 days (hip)

43
Q

what is the only DOAC and dose that is approved for PPX of VTE in acutely ill medical patients at risk ofr VTE but not at high risk for bleeding?

A

Rivaroxaban 10mg daily after discharge

recommended for 31-39 days

44
Q

What is the only DOAC recommended for the reducation of MACE (MI,CVA, Stroke and chronic CAD/PVD?)

A

Rivaroxaban 2.5mg BID with Apsirin 81mg

45
Q

How to transition Dabi to warfarin

A

start warfarin and overlap with DABI for 3 days if CrCL is greater than 50ml/min

if 30-50ml/min only overlap for 2 days

if less than 30ml/min only over lap for 1 day

46
Q

how to transition between apixaban and rivaroxaban to warfarin

A

stop DOAC and start warfarin and bridge until INR is greater than 2

47
Q

how to transition from edoxaban to warfarin

A

if pt was on 60mg dose reduce dose to 30mg then start warfarin and continue together until INR is 2

if pt was on 30mg dose reduce dose to 15mg then start warfarin and continue together until INR is 2

48
Q

what DOACS should be avoided if pt is taking one of the following

  1. phenytoin
  2. Rifampin
  3. Carbamzepine (Tegretol)
  4. St Johns wort
  5. Apalutamide
A

ALL OF THEM!

49
Q

IF pt is taking dronedarone or Ketoconazole what should you consider to do with your Dabi dose?

A

reduce from 150mg BID to 75mg BID for pts with CrCl 30-50ml/min

NO adjustment if CrCl is greater than 50

50
Q

Do you need to adjust Dabi dose for amiodarone, Verapamil or clarithromyicn?

A

NO

51
Q

what is the ONLY Combined P-GP and Strong CYP3a4 inhibitor that does not sig increase apixaban or rivaroxaban exposure so concomitant use is acceptable with out dose adjustment?

A

Clarithromycin

52
Q

If pt is on a combined Strong CYP3A4 and p-GP inhibitior (ritonavir) what should you do with the dose of apixaban?

A

Reduce by 50% if pt is already on 2.5mg BID then they need to avoid use

53
Q

What are the combined PGP and Moderate CYP3A4 inhibitors ? and how do they affect Apixaban and Riva?

A

Drondarone Verapamil
Erythromycin

Apixaban - no adjustment needed
Rivaroxaban - avoid use if crcl is 15-80ml/min

54
Q

How do you reverse DABI?

if 1st choice is not available what can you do

A

5g idarucizumab IV (2 separate 2.5g/50ml vials)
if bleeding continues and Dabi is still present in blood after 12-24 hours you can do a 2nd dose

  1. if you dont have Idarucizumab you can do PCC (aPCC) 50units/kg IV

HD can also be considered if drug level is high and pt has poor kidney function

55
Q

what do you use for the reversal of apixaban and rivaroxaban

what do you do if 1st choice is not available?

A

ANDEXXA

if andexa is not available you can use 4f -PCC at 50units/kg IV

56
Q

can you use Fresh frozen plasma for the reversal of DOAC

A

NO

57
Q

If last dose of apixaban and Rivaroxaban was greater than 8 hours ago what dose of andexxa do you use?

A

LOW DOSE

  • INITIAL IV BOLUS = 400mg at a target rate of 30mg/min
  • FOLLOW ON INFUSION= 4mg/min for up to 120mins (480mg)

total of 200mg vials is usually 5 (2 for bolus 3 for infusion)

58
Q

what is the HIGH dose of Andexa

A

INITAL BOLUS = 800mg at a target rate of 30mg/min
Follow on Infusion = 8mg/min for up to 120mg/min (960mg total)

total number of 200mg vials = 9

59
Q

In what situations would you use HIGH dose andexa for apixaban

A

if pt took apixaban dose greater than 5mg less thatn 8 hours ago or didnt know when he took it

60
Q

in what situations would you use LOW dose andexa for apixaban?

A

if pt took apixaban greater than 8 hours ago

or if pt took 2.5mg less than 8 hrs ago or unknown

61
Q

in what situations would you use HIGH dose andexa for rivaroxaban?

A

if pt took riva 10mg or more less than 8 hours ago or unknown

62
Q

in what situation would you use low dose andexa for rivaroxaban?

A

if pt took riva dose that was less than 10mg les than 8 hours ago or unknown

or if pt took any dose of rivroxaban greater than 8 hours ago

63
Q

what are the 7 indication for which DOACS have been proven inefficacious or harmful

A
  1. mechanical heart valve replacement
  2. LVAD
  3. APS
  4. ESUS
  5. TAVR
  6. within 3 months of a bioprosthetic heart valve replacement
  7. Valvular AFib
64
Q

which DOAC is a PRO DRUG that requires acidic environement for absorption? therefore will see at 20% reduction when given with antiacids (however clinically insig)

A

DABI

65
Q

what is the only DOAC that cannot be administered through enteral feeding tube?

A

DABi

66
Q

What is the DOAC that is most likely to be affect by Colectomy

A

Apixaban

67
Q

HOW do you convert from DABI to a parentaral agent?

A

stop Dabi and wait
12 hours if crcl > 30ml/min
24 hours if crcl <30ml/min

68
Q

HOW do you convert from rivaroxaban/apixaban/edoxaban to a parentaral agent?

A

STOP DOAC and start the injections at next schedule dose

69
Q

Which anticoagulation (ORAL) is the most renally cleared?

A

Dabi

then Edoxaban, then Riva, then Apix

70
Q

which parentral agent is the most renally cleared?

A

Dalteparin

then fondaparinux, enoxaparin
HEPARIN HAS NO RENAL CLEARNCE

71
Q

what is the recommended dose of apixaban for pts undergoing HD?

A

apixaban 2.5mg BID

was equal to 5mg BID for these pts

CACP (8 decks)

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