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PR - CARDIOVASCULAR SYSTEM > DOACs > Flashcards

DOACs Flashcards

1
Q

What are the FOUR
DOACs currently available?

A
  1. Apixaban
  2. Rivaroxaban
  3. Edoxaban
  4. Dabigatran (a direct thrombin inhibitor)

DARE

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2
Q

Which DOAC has a rapid onset of action?

A

Dabigatran

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3
Q

Do DOACs require frequent monitoring?

A
  • Unlike warfarin, the DOACs have a fixed dose with a predictable anticoagulant effect
  • Therefore frequent monitoring is not required
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4
Q

Why is adherence to DOACs are important?

A
  • Because DOACs have a short half life (diminishes 12 to 24 hours after the last dose is taken) which leads to a rapid fall of drug level when doses are missed
  • Fallen drug levels means less anticoagulant effects
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5
Q

Which DOACs have a reversible agent?

A
  • Dabigatran
  • Apixaban
  • Rivaroxaban
    There are no reversible agent for Edoxaban
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6
Q

What is the reversible agent for Apixaban?

A

Andexanet alfa

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7
Q

What is the reversible agent for Rivaroxaban?

A

Andexanet alfa

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8
Q

What is the reversible agent for Dabigatran?

A

Idarucizumab

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9
Q

How does Apixaban work?

A

It is a direct inhibitor of activated factor X (Factor Xa)

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10
Q

Which conditions are
Apixaban indicated for?

A
  1. Prophylaxis of VTE following knee/hip replacement surgery
  2. Treatment/ prophylaxis of DVT/PE
  3. Prophylaxis of stroke in non-valvular AF
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11
Q

What is the dose of Apixaban in the prophylaxis of stroke in non-valvular AF?

A

5mg BD

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12
Q

Which indication do you adjust the dose of apixaban for based on age and risk factors?
What are those risk factors? What dose do you give them?

A

Non-Valvular AF ONLY
Reduce dose to 2.5mg BD in patients with TWO or more of the following characteristics:
- 80+
- body-weight 60kg or less
- Serum createnine (>133)

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13
Q

What are the contraindications for
apixaban?

A
  • Active bleeding
  • Significant risk of major bleeding
  • Use with any other
    anticoagulants (except when switching therapy)
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14
Q

What are the monitoring requirements for Apixaban?

A
  • no routine anticoagulant INR monitoring required
  • Baseline Creatinine clearance, since dose needs to be reduced in renal impairment
  • Monitor for signs of bleeding or anaemia (STOP if bleeding occurs)
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15
Q

How do we adjust the dose of Apixaban in renal impairment?

A
  1. < 15ml/min
    AVOID!
  2. 15 - 29ml/min
    - Use with CAUTION
    - For prophylaxis of stroke in non-valvular AF, reduce dose to 2.5mg BD (if they were on
    5mg BD)
  3. > 30ml/min
    - Normal dose
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16
Q

What are the side effects of Apixaban?

A
  • Common: Haemorrhage
  • Others include: Anaemia, Nausea, skin reactions
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17
Q

How does Edoxaban work?

A
  • It is a direct and reversible inhibitor of activated factor X (tactor Xa)
  • prevents conversation of prothrombin to thrombin and prolongs clotting time, thereby reducing the risk of thrombus formation
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18
Q

What are the indications for Edoxaban?

A
  1. Stroke prevention in adults with non-valvular AF
    - If < 61kg: 30mg OD
    - If 61kg and above: 60mg OD
  2. Treatment/Prophylaxis of
    DVT/PE
    - if < 61kg: 30mg OD
    - If 61kg and above: 60mg OD
    - You need to had taken parenteral anticoagulants for at least 5 days before switching to Edoxaban for treatment/prophylaxis of DVT/ PE
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19
Q

What’s an easy way to remember the dose for edoxaban for ALL INDICATIONS?

A

Based on patient’s weight
If less than 61kg, then 30mg
OD
If above 61kg, then 60mg OD

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20
Q

What are the contraindications for
Edoxaban?

A
  • Active bleeding
  • Risk of major bleeding (e.g. uncontrolled severe hypertension)
  • Use with any other
    anticoagulants (except when switching)
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21
Q

What do you to
Edoxaban in surgery?

A
  • Discontinue treatment at least 24 hours before a surgical procedure
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22
Q

What are the monitoring requirements for Edoxaban?

A
  • no routine anticoagulant INR monitoring required
  • Baseline Creatinine clearance, since dose needs to be reduced in renal impairment
  • Monitor for signs of bleeding or anaemia (STOP
    if bleeding occurs)
23
Q

What are the dose adjustments for Edoxaban in renal impairment?

A
  1. <15mL/min
    - AVOID!
  2. 15-50/min
    - for all indications 30mg OD
  3. > 50ml/min
    - Normal dose
24
Q

Which drugs interact with Edoxaban and therefore require dose adjustments?

A
  • Ciclosporin
  • Dronedarone
  • Erythromycin
  • Ketoconazole
    Maximum dose of Edoxaban when taken with these is
    30 mg OD
25
Q

Side effects of edoxaban

A
  • haemorrhage
  • bleeding = delay next dose or stop treatment
  • anaemia
  • nausea
  • skin reactions
26
Q

How does Rivaroxaban work?

A
  • It is a direct inhibitor of
    Factor Xa
27
Q

What are the indications for Rivaroxaban?

A
  1. Prophylaxis of VTE following Knee OR Hip replacement surgery
  2. Treatment/ prophylaxis of VTE (DVT/PE)
  3. Prophylaxis of stroke and systemic embolism in patients with non-valvular AF
    1. Prophylaxis of atherothrombotic event following acute coronary syndrome (ACS) (with aspirin alone or aspirin and clopidogrel)
      - 2.5mg BD (very low dose - normally 10, 15, 20mg given for other indications)
  5. Prophylaxis of atherothrombotic event following in patients with coronary artery disease or symptomatic peripheral artery disease at high risk of ischaemic events (in combination with aspirin)
    - 2.5mg BD (very low dose - normally 10, 15, 20mg given for other indications)
28
Q

What are the contraindications for Rivaroxaban?

A
  • Active bleeding
  • Risk of major bleeding
  • Use with any other
    anticoagulants (except when switching)
  • Previous Stroke or TIA
29
Q

What are the monitoring requirements for Rivaroxaban?

A
  • No routine INR required
  • Baseline and regular monitoring of creatinine clearance
  • Monitor for signs of bleeding
30
Q

How should
Rivaroxaban be administered?

A
  • Swallowed whole (tablets may be crushed and mixed with water if patient is unable to swallow)
  • AND MUST be taken with food
  • MHRA WARNING
    2019 reminder that especially for 15mg and 20mg tablets, they MUST be taken with food because if taken on an empty stomach, it may lack efficacy
31
Q

How do we adjust the dose of Rivaroxaban in renal impairment?

A
  1. <15mL/min
    - AVOID!
  2. 15-49mL/min
    - For treatment/prophylaxis of
    DVT/PE and Non-valvular AF
    reduce to 15mg OD
    - for other indications: use with caution in creatinine clearance 15-29?mL/minute
32
Q

What if a patient misses a dose of rivaroxaban?

A

If taking ONCE daily
- if 12 or more hours until next dose, then take their medication as soon as they remember
- If less than 12 hours until next dose, then DONT take medication today and wait till next dose

In initial phase of treatment of DVT/PE
- This is where they take 15mg
- If they miss a dose, they need to ensure that they get 30mg total daily dose
- Therefore two tablets can be taken at once if they missed their first divided dose (15mg)

33
Q

What are the side effects of
Rivaroxaban? - COMMON

A
  • Haemorrhage
  • Menorrhagia
  • N&V
  • Diarrhoea
  • Consitpation
  • Abdomina pain
  • Pruritus
34
Q

What are the side effects of
Rivaroxaban? - LESS COMMON

A
  • Dry mouth
  • Tachycardia
  • Syncope
  • oedema
35
Q

What are the MHRA warning regarding
Rivaroxaban
after transcatheter aortic valve replacement?

A
  • Risk of death and bleeding is greater in those taking
    Rivaroxaban
    after transcatheter aortic valve replacement
  • Therefore, Rivaroxaban should be AVOIDED in these patients
  • It should also be avoided in patients with prosthetic heart valves
36
Q

How does Dabigatran work?

A
  • it is a direct thrombin inhibitor
  • It has a rapid onset of action
    (other DOACs work differently by effecting Factor Xa)
37
Q

What are the indications for dabigatran?

A
  1. Prophylaxis of VTE following total knee/hip replacement surgery
  2. Treatment of VTE/ Prophylaxis of RECURRENT VTE
  3. Prophylaxis of Stroke in non-valvular AF
38
Q

What medications taken along with Dabigatran requires dose adjustments?

A

Dose of dabigatran shaud he reduced when taken with:
- Amiodarone
or
- Verapamil
Note: Dabigatran would also need to be administered AT THE SAME TIME as
Amiodarone/Verapamil

39
Q

How would you adjust the dose of Dabigatran in renal impairment?

A
  1. < 30ml/min
    - AVOID!!
  2. 30-50 mL/min
    - Initial and maintenance dose should be adjusted based on indication
    - if also taking Verapamil, then further dose reductions
  3. > 50ml/min
    - normal dose
39
Q

Apart from renal impairment and concomitant medications, What other factor may affect dose of Dabigatran?

A
  • AGE
  • for certain indications, dose will vary it over 75 years (or even 80 years)
40
Q

Overall, what are the factors that will determine the dose of Dabigatran?

A
  1. Age
  2. Indication i.e. Non-valvular AF, prophylaxis or treatment of DVT
  3. Concomitant with Verapamil or Amiodarone
  4. Renal impairment
41
Q

What are the
contraindications of dabigatran?

A
  • Active bleeding
  • Risk of major bleeding
  • Use with other
    anticoagulants (except when switching)
42
Q

What are the monitoring requirements for dabigatran?

A
  • No routine INR required
  • Baseline and regular monitoring (at least annually) of creatinine clearance
  • Monitor for signs of bleeding
43
Q

What to do if a patient misses a dose of dabigatran?

A

If the next dose is less than 6 hours away, missed dose should be skipped and normal dosing continued

44
Q

What are the side effects of dabigatran?

A

Common:
- Haemorrhage
- Nausea
- Anaemia

45
Q

What are the MHRA warnings regarding patients with antiphospholipid syndrome and are taking DOACs?

A
  • antiphospholipid syndrome is an immune disorder which increases the risk of blood
    clots
  • There is an increased risk of recurrent thrombotic events in these patients taking DOACs
  • DOACS are NOT recommended in these patients, should consider switching to vitamin K antagonist (e.g. Warfarin)
46
Q

Can be DOACs be taken during pregnancy or breastfeeding?

A

NO

47
Q

Which DOAC is contraindicated in creatinine clearance of 15-29ml/ min?

A

Dabigatran

48
Q

DOACs are contraindicated at less than 15ml/min CrCl, are vitamin K antagonists (e.g. Warfarin) contraindicated too?

A
  • No, they are not
    contraindicated in renal impairment
  • INR needs to be monitored more frequently
49
Q

Can DOACs be used in patients with prosthetic valves?
What about warfarin?

A

All DOACS - NO!
VKA’s (e.g. warfarin), YES

50
Q

Which DOAC cannot be crushed and administered via enteral feeding tube?

A
  • Dabigatran
  • AIl DOACs and VKAs can
51
Q

Can DOACs be used in stroke prevention in valvular AF?

A

No
Only VKAs (e.g. Warfarin) can be used in valvular AF

52
Q

Which DOAC is the only one of it’s class that is indicated for preventing atherothrombotic
events following acute coronary syndromes (e.g. Myocardial infarction)?

A
  • Rivaroxaban
  • normally low dose i.e. 2.5mg BD
  • In combination with either Aspirin or Aspirin & Clopidogrel (combination)
  • NOTE: The other DOACs are not indicated for this purpose

PR - CARDIOVASCULAR SYSTEM (48 decks)

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