Dosing

Question 1

Dose of UFH for VTE treatment

Answer 1

IV 80 units/kg bolus, followed by continuous infusion of 18 units/kg/hour

Question 2

Dose of UFH for VTE prophylaxis in medically-ill patients

Answer 2

SC 5000 units q8-12 hours for LOS or until fully ambulatory

Question 3

Dose of UFH for VTE prophylaxis in non-ortho surgery patients

Answer 3

• SC 5000 units q8-12 hours with initial dose at least 2 hours prior to surgery
• May postpone until after surgery
• Continue until fully ambulatory and risk of DVT has diminished (~10 days)

Question 4

Dose of UFH for VTE prophylaxis in ortho surgery patients

Answer 4

• SC 5000 units q8-12 hours, initial dose at least 12 hours pre-op or at least 12 hours post-op once hemostasis achieved
• Continue for 10-14 days (max 35 days)
• If extended duration needed, consider changing to an OAC or alternative SC agent

Question 5

Dose of UFH for PCI with no previous use of antithrombotic use

Answer 5

• IV 2000-5000 units (max 50-70 units/kg) to achieve ACT of 250-300 s
• Repeat bolus (max 10,000 units ) PRN to maintain ACT throughout

Question 6

Dose of UFH for PCI with previous use of GPIIb/IIIa inhibitor

Answer 6

• IV 2000-5000 units (max 50-70 units/kg) to achieve ACT of 250-300 s
• Repeat bolus (max 7000 units ) PRN to maintain ACT throughout

Question 7

Dose of UFH for PCI with previous use of UFH/LMWH

Answer 7

Always check ACT prior to administration, if > 2000 s, no bolus

Question 8

Dose of enoxaparin for VTE treatment

Answer 8

SC 1 mg/kg q12 hours (preferred)
SC 1.5 mg/kg QD

If CrCl < 30: 1 mg/kg QD

Question 9

Dose of enoxaparin for VTE prophylaxis in medically-ill and surgery patients

Answer 9

SC 40 mg QD until ambulatory

Question 10

Dose of enoxaparin for THR / HFS

Answer 10

SC 40 mg QD or 30 mg BD for 10-14 days, up to 35 days

Question 11

Dose of enoxaparin for VTE prophylaxis in patients with renal impairment

Answer 11

CrCl 30-50: SC 30 mg q12 hours, consider checking anti-factor Xa
CrCl <30: SC 20 or 30 mg QD

Question 12

Dose of enoxaparin for PCI usually

Answer 12

Last SC LMWH 8-12 hour before: IV 0.3 mg/kg bolus
Last SC LMWH >12 hour before: use UFH
Last SC LMWH < 8 hour before: no need for further LMWH

Question 13

Dose of enoxaparin for PCI in MI patients with previous thrombolytic

Answer 13

• Start between 15 min before and 30 min after PCI
• If < 75 y: IV bolus 30 mg followed by 1 mg/kg q12 hours
• If at least 75 y: omit bolus, followed by 0.75mg/kg q12 hours
• Treat for 48 hours, up to 8 days or until revascularisation

Question 14

Dose of bivalirudin for VTE treatment

Answer 14

IV 015-0.2 mg/kg/hour
Adjust to aPTT 1.5-2.5x of the baseline value

Question 15

Dose of bivalirudin for PCI

Answer 15

• IV 0.75 mg/kg bolus, followed by IV infusion 1.75 mg/kg/hour for up to 4 hours after PCI

Question 16

Dose of fondaparinux in VTE treatment

Answer 16

< 50 kg: SC 5 mg QD
50-100 kg: SC 7.5 mg QD
>100 mg: SC 10 mg QD

Question 17

Dose of fondaparinux in PCI

Answer 17

SC 2.5 mg/day

Question 18

Dose of dabigatran for VTE treatment

Answer 18

• Parenteral anticoagulant for at least 5 days
• 150 mg BD

CrCl < 50 + concomitant PGP inhibitor: Avoid dabigatran

Question 19

Dose of dabigatran for VTE prophylaxis

Answer 19

• Ensure hemostasis achieved
• Start within 1-4 hours post-op
• 220 mg/day x 10 days (TKR) or 28-35 days (THR)

CrCL 30-50: use with caution, 150 mg OM for same duration as above

Question 20

Dose of rivaroxaban for VTE treatment

Answer 20

15 mg BD x 3 weeks
20 mg/day for up to 6 months
10 mg OM for extended (or 15 mg OM by EMA)

CrCl <30: avoid

Question 21

Dose of rivaroxaban for VTE prophylaxis

Answer 21

• Ensure hemostasis achieved
• Start 6-10 hours post-op
• 10 mg/day x 2 weeks (TKR) or 5 weeks (THR)

For medically ill: 10 mg/day for up to 31-39 days

Question 22

Dose of apixaban for VTE treatment

Answer 22

10 mg BD x 7 days
5 mg BD for up to 6 months
2.5 mg BD (if extended)

CrCL 15-29: use with caution
HD: Avoid

Question 23

Dose of apixaban for VTE prophylaxis

Answer 23

• Ensure hemostasis achieved
• 12-24 hours post-op
• 2.5 mg BD x 10-14 days (TKR) or 32-35 days (THR)

Question 24

Dose of edoxaban for VTE treatment

Answer 24

• Initial parenteral anticoagulant for at leats 5 days
• 60 mg/day

CrCL 30-50 OR body weight 60 or below: 30 mg
CrCL > 95: avoid

Question 25

Dose of edoxaban for VTE prophylaxis

Answer 25

30 mg/day

Question 26

Dose of alteplase for PE treatment

Answer 26

IV 100 mg over 2 hours OR 0.6 mg/kg over 15 mins (max 50 mg)

Question 27

Dose of dabigatran for SPAF

Answer 27

150 mg BD

110 mg BD if at least 80 y.o., or use of PGP inhibitors or high risk of bleed
CrCl 30-50: No dose adjust unless DDI
CrCl <30: contraindicated
(FDA) CrCl 15-30: 75 mg BD

Question 28

Dose of rivaroxaban for SPAF

Answer 28

20 mg per day

(FDA) 15 mg per day for CrCl 15-49
CrCl 30-50: 15 mg per day
CrCl 15-30: use with caution
CrCl <15: contraindicated

Question 29

Dose of apixaban for SPAF

Answer 29

5 mg BD

2.5 mg BD for any 2:
- at least 80 y.o.
- weight 60 kg and below
- SCr at least 1.5 mg/dL or 132.6 mmol/L

CrCl 30-50: usual dose
CrCl 15-29 (if no other conditions): 2.5 mg BD
CrCl <15: unclear
HD: normal dose

Question 30

Dose of edoxaban for SPAF

Answer 30

60 mg per day

30 mg per day if any:
- CrCl 30-50
- weight 60 kg and below
- Concomitant use of verapamil, quinidine, dronedarone

CrCl 15-30: 30 mg per day
CrCl <15: not recommended

Question 31

Iron supplementation

Answer 31

• 1000-1500 mg of elemental iron per cycle x 3-6 months
• Usual 200-300 mg per day
• PO iron polymaltose 100 mg OD/BD
• PO ferrous gluconate (Sangobion) 1 tab TDS (30 mg x 3)

Question 32

Vit B12 supplementation

Answer 32

Parenteral:
- IM or SC 1000 mcg per day x 1 week
- IM or SC 1000 mcg weekly x 4 weeks
- IM or SC 1000 mcg monthly for life

Oral:
- PO 1000 mcg daily

Question 33

Folic acid supplementation

Answer 33

PO 1 mcg daily for 2-4 months until recovery