Module 2 exam 1 Dosage adjustment Flashcards

1
Q

What to do when INR<2 (or 2.5 if goal is 2.5-3.5)

A

Increase weekly dose by 5-15%

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

What to do when INR is 3.1-3.5 (3.6-4 if goal is 2.5-3.5)

A

decrease weekly dose by 5-15%

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

What to do when INR is 3.5-4 (4.1-4.5 if goal is 2.5-3.5)

A

hold 0-1 dose
decrease by 10-15%

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

What to do when INR>4 (>4.5 if goal is 2.5-3.5)

A

hold 0-2 doses
decrease by 10-15%

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

What to do when some doses are different than the doses taken most days

A

Space out the separate doses by as much as possibe
ie- if 2 doses different- M,F
If 3 doses different M,W,F
Switch/flip
Never choose only 1 day a week different dose

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

What is a switch/flip

A

3 days at lower dose and 4 days at higher dose, we switch to 3 days at higher dose and 4 days at lower dose

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

What is bridging therapy? when is it used?

A

Bridging therapy is when a patient needs to come off warfarin around a procedure that has bleeding risk

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

When to stop warfarin if bridging is needed

A

5 days before surgery

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

When to stop aspirin if bridging is needed

A

a week before procedure

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

What to do once we stop warfarin and aspirin during bridging

A

Start enoxaparin a day after stopping warfarin (there will be a day with no medication at all)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

What to do with different doses of enoxaparin when we approach surgery day

A

If enoxaparin is 12 hr dosing, no enoxaparin the night before and the day of procedure

If enoxaparin is 24 hr dosing, The last dose should be 50% of the dose the morning before the surgery

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

How do we start warfarin back up after surgery on enoxaparin

A

overlap warfarin and enoxaparin for atleast 5 days AND INR>2

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

What is the max INR should increase or decrease ina day

A

0.3 increase or decrease.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

How do we monitor patients on UFH

A

aPTT

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Goal aPTT

A

1.5-2.5
low aPTT we need to increase dose

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

What are the two types of thrombocytopenia

A

HAT (type 1)
HIT (type 2)

17
Q

Difference between HAT and HIT

A

HAT- platelets>100,000

HIT- platelets <100,000
or platelet decrease by more than 50%
Occurs in 7-14 days

18
Q

Tx of HIT

A

Stop all heparin products
give alternate anticoagulant (lepirudin, argatroban, bivalirudin, fondaparinux)
Do not give warfarin until platelet >150,000

19
Q

Can we continue all heparin products in HAT

A

Yes, only stop in HIT)

20
Q

Compare advantage of LMWH and UFH

A

LMWH has better bioavailability and more predictable dosing
longer plasma life
improved subq
lower risk of HIT

21
Q

What are the different doses of enoxaparin

A

Prophylaxis after surgery- 30 mg SQ, Q 12 H
Prophylaxis for hospital- 40 mg QD subq
Tx dose- 1 mg/kg Q12H
or
1.5 mg/kg/day

22
Q

Enoxaparin doses for Crcl<30

A

prophylaxis- 30 mg SQ daily
tx- 1mg/kg

23
Q

What kind of drug is enoxaparin

24
Q

Which patients to monitor for LMWH (enoxaparin)

A

Monitor anti Xa levels of
Children, severe kidney failure, obesity, pregnancy

25
Different ways of monitoring anti Xa in LMWH pts
If pt is on twice a day enoxaparin- monitor PEAK anti Xa level 4 hours after a dose is give. (concentration goal 0.6-1) If patient is on once a day dosing- Check TROUGH concentration immediately before a dose is given to see if it has been cleared. (concentration goal 0.1-0.3)
26
Name an injectable Fxa inhibitor
Fondaparinux
27
What is fondaparinux used for? doses?
Used for tx of DVT or PE prophylaxis -2.5 mg tx doses <50 kg- 5 mg QD 50-100 kg- 7.5 mg >100 kg- 10 mg
28
In what situations can we not use Fondaparinux
Do not use CrCL<30 Do not use prophylaxis<50 kg Can be used if pt has HIT diagnosis
29
Name DTI drugs. WHat are they used for
Lepirudin, Bivalirudin, Argatroban All reserved for use when pt is diagnosed with HIT
30
Argatroban important point
One of the few drugs dosed hepatically, adjust dose based on renal impairment. ARGATROBAN CAN FALSLY ELEVATE INR
31
When to discontinue medications when using with warfarin
stop other meds when INR is 2, except argatroban, Stop argatroban when INR is 4
32
When using warfarin and using enoxaparin to replace or supplement warfarin, we use therapeutic dose
Dont forget