Lecture 6 - VTE 2

Question 1

High Risk for VTE score

Answer 1

> 4 points

Question 2

Low risk for VTE score

Answer 2

0 - 3 points

Question 3

Hospitalized, acutely ill pt, risk > 4, increased risk of thrombus then….

Answer 3

LMWH, LDUH, or Fondaparinux

if critically ill then use LMWH or LDUH

Question 4

Hospitalized, acutely ill pt, risk > 4, with bleeding or at high risk for major bleeding then….

Answer 4

GCS or IPC (nonpharm)

switch to pharm treatment if bleeding risk decreases

Question 5

Hospitalized, acutely ill pt, risk <3, low risk of thrombus then….

Answer 5

no med, can do nonpharm if want but don’t really need

Question 6

Caveat to Hospizatilized, acutely ill pt….

Answer 6

no extension of anticoagulants after discharge

Question 7

Go to for patients with solid tumors?

Answer 7

LMWH

Question 8

treatment for chronically immobilized patients?

Answer 8

don’t have to do prophylaxis due to body adjusting

Question 9

treatment for ppl traveling long distances and increased risk of VTE

Answer 9

moving, calf muscle exercises, use compression stockings (15-30mmHg @ Ankle)

Question 10

Total Hip or total Knee Arthroplasty Treatment

Answer 10

10-14 days of LMWH (preferred), Fonda, apixaban, dabigatran, rivaroxaban, LDUH, warfarin, ASA or IPC

Question 11

Hip Fracture Surgery Treatment

Answer 11

10-14 days of LMWH (preferred), Fonda, LDUH, warfarin, ASA or IPC

Question 12

Major orthopedic surgery treatment

Answer 12

1. extend therapy in outpatient period up to 35 days
2. can add IPC
3. use apixaban or dabigatran if don’t like injection, or rivaroxaban or warfarin

Question 13

Lovenox (Enoxaparin) LMWH dosing most patients…

Answer 13

40 mg SQ daily

Question 14

Lovenox (Enoxaparin) LMWH dosing for THA/HFS

Answer 14

40 mg SQ daily or 30 mg SQ q12h

Question 15

Lovenox (Enoxaparin) LMWH dosing for TKA

Answer 15

30 mg SQ q12h

Question 16

Lovenox (Enoxaparin) LMWH dosing CrCl < 30ml/min

Answer 16

30 mg SQ daily

Question 17

Lovenox (Enoxaparin) LMWH dosing obesity/ BMI >40

Answer 17

increase dose by 30%

Question 18

injection of Lovenox instructions

Answer 18

1. Wash & Dry hands
2. Sit or Lie comfortably so that you can see abdomen
3. Choose area left or right side, 2in from Belly button (love handles)
4. clean injection site
5. pinch 1 inch of skin, inject, dispense syringe

** don’t expel air and rotate sites **

Question 19

UFH dose in typical hospital?

Answer 19

5000 units SQ 8-12hr, won’t need renal adjustment

Question 20

fondaparinux (Arixtra) dosing

Answer 20

2.5mg SQ daily for most ppl

Contraindicated <50 kg pts, CrCl 30-50ml/min

Question 21

Dabigatran for prophylaxis dosing

Answer 21

110 mg PO 1-4hr after surgery and hemostasis, or 220 mg if not on day of surgery and after hemostasis

Question 22

Counseling for Dabigatran

Answer 22

dyspepsia
don’t chew/crush
keep in same packaging

Question 23

Dabigatran indications

Answer 23

THA

off-label for TKA

Question 24

Rivaroxaban (Xarelto) for prophylaxis indications

Answer 24

THA, TKA, acutely ill patients

Question 25

Rivaroxaban (Xarelto) for prophylaxis dosing (TKA + THA)

Answer 25

10 mg qd for 10-14 days (TKA) up to 35 days (THA)

Question 26

Rivaroxaban counseling

Answer 26

Doses < 15mg can be taken without regard to meals, >15mg = need food can crush/mix in applesauce or water

Question 27

Rivoroxaban DI

Answer 27

avoid using with strong dual p-gp & CYP3A4 inhbitors/inducers

Question 28

Eliquis for prophylaxis indications

Answer 28

THA or TKA

Question 29

Eliquis for prophylaxis dosing

Answer 29

2.5mg BID starting 12-24 days post-op, for 10-14 days (TKA) up to 35 days (THA) favored due to being safe

Question 30

UFH for VTE Treatment dosing

Answer 30

80 unit/kg IV bolus (10K unit max) 18unit/kg/hr continuous, adjusted as needed using aPTT

Question 31

UFH for VTE is preferred in....

Answer 31

pts who are hemodynamically unstable, need thrombectomy, renal failure, obesity?

Question 32

Enoxaparin (Lovenox) VTE treatment dosing

Answer 32

1mg/kg SQ q12hr (preferred) 1.5 mg/kg SQ daily If CrCL < 30, use 1mg/kg SQ daily ** Round to nearest 10mg **

Question 33

Fondaparinux for VTE treatment dosing

Answer 33

< 50kg = 5 mg SQ daily 50-100 kg = 7.5 mg SQ daily > 100 kg = 10 mg SQ daily

Question 34

Fondaparinux for VTE renal impairment adjustment

Answer 34

CrCl 30-50 = use caution | CrCl < 30 = contraindicated

Question 35

How to decide which oral option to use?

Answer 35

1. Efficacy 2. Safety 3. Feasibility 4. Cost

Question 36

Warfarin Bridging

Answer 36

1. Start therapeutic dose UFH, LMWH, or fondaparinux w/ Warfarin 2. Bridge for atleast 5 day, INR > 2 for >24hrs 3. Discontinue short-acting anticoagulants and dose adjust warfarin as needed

Question 37

Dabigatran & Edoxaban switching

Answer 37

1. Start with therapeutic dose UFH, LMWH or fondaparinux for 5 days 2. Switch to dabigatran or edoxaban after that

Question 38

Oral options without Bridge/Overlap

Answer 38

Rivaroxaban and Apixaban

Question 39

Rivaroxaban Dosing VTE treatment

Answer 39

15 mg po BID X 21 days with meals, then 20 mg po daily with meals avoid using in CrCl < 30ml/min

Question 40

Apixaban Dosing VTE treatment

Answer 40

10 mg PO BID 7 days, then 5 mg PO BID no adjustment necessary in renal impairment reduce dose 50% if given with dual CYP3A4/p-gp inhibitor

Question 41

Dabigatran Dosing VTE treatment

Answer 41

5 days of parenteral AC, then 150mg PO BID

Question 42

Edoxaban Dosing VTE treatment

Answer 42

5 days of parenteral AC, then weight based.... ``` >60kg = 60mg daily <60kg = 30mg daily ``` *** Don't use if CrCl > 95ml/min = cleared to quickly **** also don't use < 30 ml/min

Question 43

Warfarin for VTE Treatment

Answer 43

cannot be started as monotherapy, must have appropriate bridging with parenteral AC effective long term management of acute VTE

Question 44

Typical starting dose Warfarin for VTE treatment?

Answer 44

5mg po ** 2.5 mg in 65+, frail, malnourished, live/kidney disease, HF, DI

Question 45

Why do we still use warfarin?

Answer 45

- Renal impairemnt - Obesity - those high risk for bleeding bc they will be monitored frequently

Question 46

Frequency of Warfarin monitoring

Answer 46

Inpatient - daily out of INR range = 2-3 times per week once stable for 1-2 weeks, every 2-4 weeks up to every 12 weeks

Question 47

Provoked VTE duration of coag

Answer 47

3 months regardless of Risk of bleeding Extend > 3 month if cancer associated or second VTE

Question 48

Unprovoked VTE duration of coag

Answer 48

at least 3 months Proximal DVT or PE, with low-mod risk of bleeding..extend > 3 months with high risk of bleeding = 3 month

Question 49

For patients at elevated risk of recurrent VTE, how long should they have anticoagulants therapy?

Answer 49

6 months atleast

Question 50

Padua Score

Answer 50

``` >4 = high risk 0-3 = low risk ```

Question 51

1 pt Padua Score

Answer 51

``` Age > 70 Heart or Respiratory Failure Acute MI or ischemic stroke Acute infection BMI > 30 Hormonal treatment ```

Question 52

2 pt Padua Score

Answer 52

Recent trauma/surgery < 1 month

Question 53

3 pt Padua Score

Answer 53

Active cancer previous VTE Reduce mobility Already known thromboembolic condition