Module 2 exam 1 Dosage adjustment

Question 1

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

Answer 1

Increase weekly dose by 5-15%

Question 2

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

Answer 2

decrease weekly dose by 5-15%

Question 3

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

Answer 3

hold 0-1 dose
decrease by 10-15%

Question 4

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

Answer 4

hold 0-2 doses
decrease by 10-15%

Question 5

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

Answer 5

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

Question 6

What is a switch/flip

Answer 6

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

Question 7

What is bridging therapy? when is it used?

Answer 7

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

Question 8

When to stop warfarin if bridging is needed

Answer 8

5 days before surgery

Question 9

When to stop aspirin if bridging is needed

Answer 9

a week before procedure

Question 10

What to do once we stop warfarin and aspirin during bridging

Answer 10

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

Question 11

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

Answer 11

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

Question 12

How do we start warfarin back up after surgery on enoxaparin

Answer 12

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

Question 13

What is the max INR should increase or decrease ina day

Answer 13

0.3 increase or decrease.

Question 14

How do we monitor patients on UFH

Answer 14

aPTT

Question 15

Goal aPTT

Answer 15

1.5-2.5
low aPTT we need to increase dose

Question 16

What are the two types of thrombocytopenia

Answer 16

HAT (type 1)
HIT (type 2)

Question 17

Difference between HAT and HIT

Answer 17

HAT- platelets>100,000

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

Question 18

Tx of HIT

Answer 18

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

Question 19

Can we continue all heparin products in HAT

Answer 19

Yes, only stop in HIT)

Question 20

Compare advantage of LMWH and UFH

Answer 20

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

Question 21

What are the different doses of enoxaparin

Answer 21

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

Question 22

Enoxaparin doses for Crcl<30

Answer 22

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

Question 23

What kind of drug is enoxaparin

Answer 23

LMWH

Question 24

Which patients to monitor for LMWH (enoxaparin)

Answer 24

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

Question 25

Different ways of monitoring anti Xa in LMWH pts

Answer 25

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)

Question 26

Name an injectable Fxa inhibitor

Answer 26

Fondaparinux

Question 27

What is fondaparinux used for? doses?

Answer 27

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

Question 28

In what situations can we not use Fondaparinux

Answer 28

Do not use CrCL<30
Do not use prophylaxis<50 kg
Can be used if pt has HIT diagnosis

Question 29

Name DTI drugs. WHat are they used for

Answer 29

Lepirudin, Bivalirudin, Argatroban

All reserved for use when pt is diagnosed with HIT

Question 30

Argatroban important point

Answer 30

One of the few drugs dosed hepatically, adjust dose based on renal impairment.

ARGATROBAN CAN FALSLY ELEVATE INR

Question 31

When to discontinue medications when using with warfarin

Answer 31

stop other meds when INR is 2, except argatroban,

Stop argatroban when INR is 4

Question 32

When using warfarin and using enoxaparin to replace or supplement warfarin, we use therapeutic dose

Answer 32

Dont forget