IV Anticoagulants Flashcards
Heparin MOA
Binds with antithrombin to inactivate factor II and X
Also inactivates IX, XI, and XII
Heparin onset
SQ-20-30 minutes
IV- immediately
Heparin PK/PD
No renal dose adjustment
Recommended anticoagulant in dialysis patients
Heparin VTE Treatment dose
80 units/kg IV, then 18 units/kg/hr IV
Heparin ACS treatment dose
60 units/kg IV, then 12 units/kg/hour IV
Heparin is dosed based on:
Total body weight
Heparin Titration
Stop at Q6 hour aPTT check after 2 aPTTs in range –> daily aPTT checks
Therapeutic heparin indications, monitoring of efficacy and monitoring of AE?
VTE, afib, ACS
aPTT/anti-Xa per protocol
Platelets, Hgb/Hct
Prophylaxis heparin indications, monitoring of efficacy and monitoring of AE?
VTE prevention
None
Platelets, Hgb/Hct
Lovenox (enoxaparin) MOA
Binds with antithrombin to inactivate X and II (mainly X)
Lovenox Onset and duration
Peaks 3-5 hrs
Last ~12 hours
Lovenox requires ____ and is dosed on ____
Renal adjustment
Total body weight
Lovenox Therapeutic used when and dose
ACS, VTE (PE/DVT)
1mg/kg SQ q12h
Lovenox Alt Dose
1.5 mg/kg SQ daily
Lovenox prevention of VTE dose for medical/surgical if CrCl greater than 30
40 mg SQ daily
Lovenox prevention of VTE/propylaxis dose for knee replacement if CrCl greater than 30
30 mg SQ BID
Lovenox therapeutic dose for medical/surgical if CrCl less than 30
What if CrCl greater than 30?
1 mg/kg SQ daily
1 mg/kg SQ Q12h
Lovenox prevention of VTE/propylaxis dose if CrCl less than 30
30 mg daily
Lovenox monitoring
Anti-Xa
Monitoring is indicated when used in:
Pregnancy
Extremes of weight (less than 45 or greater than 190 kg)
CrCl less than 30
High risk of bleeding or VTE
**Anti-Xa monitoring is ordered
4 hours after dose for peak concentration
dose adjustments = order after 4 hrs
Fragmin (dalteparin) MOA
Binds with anti-thrombin to inactivate factor X and II
Fragmin Onset and excretion
Peaks 1-2 hrs
Renally excreted
Fragmin Onset and excretion
Peaks 1-2 hrs
Renally excreted
Fragmin VTE Prophylaxis during acute illness dose
5000 units SQ daily
Reversal of Heparinoids Agent =
Protamine sulfate
Protamine sulfate dose to reverse Heparin
1 mg neutralizes ~100 units of heparin
MAX = 50 mg
Protamine sulfate dose to reverse Enoxaparin
Anti-Xa activity will never be completely neutralized
Dependent on last dose administered
Thrombocytopenia includes:
Thrombocytopenia (50% platelet fall or less than 150)
Timing (5-10 days after heparin use)
Thrombosis
Arixtra (fondaparinux) MOA
Inhibit Factor Xa
Can be used in HIT
Must be renally adjusted
Arixtra Prophylaxis Dosing
2.5 mg SQ daily
Arixtra Treatment Dosing
Less than 50 kg: 5 mg SQ daily
50-100kg: 7.5 mg SQ daily
Greater than 100: 10 mg SQ daily
Argatroban MOA
Direct thrombin inhibitor
Agratroban Indication
Prevention/treatment of thrombosis in HIT pts
PCI intervention pts with HIT or history of HIT
Agratroban Monitoring and other considerations
aPTT
Prolongs INR
Renal dose adjustment
Warfarin + Argatroban
For at least 5 days before discontinuation of argatroban
D/C Less than 2 mcg/kg/min infusion of argatroban if
INR greater than 4
Repeat INR 4-6 hrs later and restart if INR is less than 2
D/C Greater than 2 mcg/kg/minute infusion of argatroban if:
Reduce dose to 2 mcg/kg/min
Check INR 4-6 hrs after adjustment (stop if INR greater than 4)
Then recheck 4-6 hrs and restart if INR is less than 2.
Angiomax (bivalirudin) MOA
Direct thrombin inhibition
Renal adjust for CrCl less than 30
Angiomax Monitoring
HIT- aPTT
PCI- ACT
