dose Flashcards
DVT UFH doses
80 units/kg –> 18units/kg/hr infusion
DVT LMWH dose
enoxaparin 1mg/kg Q12H or 1.5mg/kg OD
- enoxaparin renal <30ml/min = 1mg/kg OD
DVT riva dose
15mg BD 3wks —> 20mg OD 6mnths —> 10mg OM (prophy)
DVT apix dose
10mg BD 7d —> 5mg BD 6mnths —> 2.5mg BD (prophy)
DVT rTPA dose
100mg over 2h or 0.6mg/kg over 15mins (max 50mg)
DVT UFH prophylaxis
5000units Q8-12h
[medically ill, non-ortho, ortho -TKR, THR 10-14d~35d]
DVT enoxaparin prophylaxis
40mg OD until ambulatory
or 30mg BD - surg TKR,THR 10-14d ~ 35d
DVT dabigatran prophylaxis
Haemostasis achieved
1-4h post surg 220mg/day (10d TKR)
(28-35d THR)
DVT renal dabi
Crcl 30-50ml/min (caution) 150mg OM same duration as above
Crcl <50ml/min + PGPi (avoid)
DVT riva prophy
10mg OD
TKR: 2wk
THR: 5wk
medically ill for 31-39d
DVT apix prophy
Haemostasis achieved, 12-24h post surg
2.5mg BD (10-14d TKR)
(32-35 days THR)
DVT riva renal
Crcl < 30ml/min (avoid)
DVT apix renal
Crcl 15-29ml/min (caution)
HD (avoid)
DVT edoxaban renal
30mg/day
* Crcl 30-50ml/min
* or BW <60kg
If renal function >95ml/min (too good, tx failure)
DVT LMWH renal
Severe renal (crcl <30ml/min): 1mg/kg OD
- same for cancer, preg
prophy:
* Mod renal (30-50ml/min): 30mg BD
Consider anti-Fxa levels
- Severe renal = 20-30mg OD
AF dabig dose
150mg BD.
- 110mg BD (if =/>80yo/ use PGPi/ high risk of bleed)
- no crcl dose adj unless CI <30ml/min
AF riva dose
20mg OD
- crcl 30-50ml/min = 15mg OD
- crlc <15 ml/min = CI
AF apix dose
5mg BD
- 2.5 mg BD (if any 2: Age =/> 80yo, Weight =/<60kg, Scr =/> 1.5mg/dL/ 132.6mmol/L)
crcl 15-29: 2.5mg BD
crcl <15ml, HD is approved by no dose???
AF edoxaban dose
60mg OD
- 30mg OD (any: crcl 30-50/ weight =/>50kg, concomitant: werapamil, quinidine, dronedaron)
Crcl <15ml/min = not recomm
AMI PCI UFH
2000-5000 units (no more than 50-70 units/kg) to achieve ACT of 250 – 300 seconds;
repeat bolus (max 10 000 units) as needed to maintain ACT throughout PCI.
AMI PCI LMWH
If < 75yo, bolus IV 30mg followed by SQ 1mg/kg Q12H
if ≥75yo, omit bolus, followed by SQ 0.75mg/kg Q12H
duration of 48h and up to 8d or until revascularisation.
AMI SAPT
Load 300mg (no load if currently on aspirin)
f/b: 100mg OM (lifelong)
DAPT clopidogrel doses
clopidogrel (CCS) Load 300mg (6h onset) or 600mg (2h onset)
f/b: 75mg OM
extended therapy (beyond 12mnth): 75mg OD
DAPT ticagrelor dose
Load: 180mg
f/b : 90mg BD ~ 12mn
extended therapy (beyond 12mnth): 60mg BD —non MAF
DAPT eptifibatide dose
Double bolus of 180ug/kg iv
(10min interval)
Follow: infusion 2.0ug/kg/min for 72h
short t1/2, need infusion.
fibrinolytics AIS
within 3hr/ 4.5hr
0.9mg/kg (max 90mg)
stroke VTE prophylaixs
LMWH within 48h. after 24h of rTPA
- due to immobile state
- monitor bleedign risk within 72hr
40mg OD until ambulatory
when and how long is DAPT administered in AIS
within 24h - 48h (if given rTPA)
ASAP if not rTPA eligible
(90d: major ICAS, non-cardioembolic)
(21d: minor stroke, high risk TIA)
high intensity statins
atorvastatin 40-80mg
rosuvastatin 20-40mg
add in ezetimbe if LDL > 1.8mmol/L
HBP control
ACEi
CCB
thiazide diuretic
management of pernicious anemia/ vit 12 deficiency anemia
- IM, SC vit B12 1000ug daily for 1 wk
- Follow: 1000 ug weekly x 4wks
- Follow: 1000ug mnthly for life
PO often insufficient
- PO Vit B12, 1000ug ~ 2000ug daily
Absorbed by mass action, not rely on intrinsic factor action
*or when IF not that low
folate deficiency tx
1mg/d folate for 1-4mnths
Or
Until hematologic recovery, normal Hb
Multivitamin (sangobion, ferrous gluconate)
tx for Fe deficiency
Sufficient Fe = 1000 - 1500mg of elemental Fe for complete supplementation
Ferrous gluconate tab 30mg sangobion (12%)
Iron polymaltose 100mg Maltofer (100%)
(20-30 ~~ 200mg). 3-6 mnths to replenish
management of aplastic anemia
1) Withdraw causative drug
2) improve peripheral blood counts Transfusion of erythrocytes and PLT
- Granulocyte-macrophage CSF: sargramostim,
- G-CSF: filgrastim, pegfilgrastim
- IL-14
3) minimise risk for infections
* Ab prophylaxis, antifungal
* Neutrophil count <500 cells/mm3
4) Haematopoietic stem cell transplant (HSCT)
5) Immunosuppressants while bone marrow recovers
* Glucocorticoids
* Ciclosporin
* Cyclophosphamide
* Azathioprine
* Antithymocyte Ig
do not heavily transfuse
iron overload
require Fe chelation
- Defoxamine
- Deferasirox
tx for HIT
1) Hold offending drug
Recover in 1-2 days. Complete in 1wk
Ab may persist for years, do not restart. avoid indefinitely
2) KIV corticosteroid if severe
3) Heparin-induced thrombocytopenia
*DOAC: dabigatran (off-label)
tx for immune thrombocytopenia
1) Withdraw causative drug
2) Immunosuppressants (KIV)
- Glucocorticoids
- Ciclosporin
- Cyclophosphamide
- Azathioprine
- Antithymocyte Ig
3) Transfusion of PLT
Clinically sig bleeding
agranulocytosis tx
1) Withdraw causative drug
- blood count usually returns to norm in 2-4wks (~4-24days)
2) Prophylactic administration of hematopoietic GF
* GM -CSF: sargramostim
○ More potent, more ADR as it stimulates diff type of blood cells
* G-CSF: filgrastim (sc 300mcg/day), pegfilgrastim
- Weekly monitor WBC count
- Esp for pt with clozapine
tx for hemolytic anemia
1) Withdraw causative drug
- RBC transfusion for pt with low Hb
- Haemodialysis in acute RF
- Steroids, Ig in serious cases
- Autoimmune hemolytic anaemia
Rituximab (human anti-C20 Mab) used
drugs that cause megaloblastic anemia + tx
- Antimetabolite = Hold off drug
○ MTX, chemotherapy - Co-trimoxazole = Folinic acid 5-10mg QDS
○ Esp in folate/ vit B12 deficient - Phenytoin, phenobarbital = Switch drug/ folic acid
○ Inhibit folate absorption or catalyse folate catabolism
§ Folic acid 1mg/day but may decr phenytoin efficacy
drugs to tx anemia (nutrient, erythropoeisis)
- Nutrients
○ Vit B12, folate deficiency
○ Fe deficiency - Erythropoiesis-stimulating agents
○ darbepoetin alfa, epoetin alfa
tx for leukemia, myelodysplastic syndromes & lymphoma
○ Corticosterois, immunosuppressants, cytotoxic (chemo), targeted synthetic drugs, biologics
○ Supportive therapies for cytopenia
- anemia, neutropenia, thrombocytopenia
neutropenia drugs
Myeloid GF
- granulocyte colony sitmulating factor (G-CSF)
○ recombinant human GCSF – filgrastim
○ Filgrastin covalently conjugated with PEG – pegfilgrastin - GM-CSG (macrophage)
○ recombinant human GCSF – sargramostim
thrombocytopenia tx drugs
Megakaryocyte GF/ plt-stimulating agents
* Recombinant IL-11: oprelvekin
* Fc-fusion protein thrombopoietin receptor agonist (romiplostim)
- PO nonpeptide thrombopoietin receptor agonist (eltrombopag)
