New Oral Anticoagulants

Question 1

Dabigatran, Rivaroxaban and Apixaban Indications

Answer 1

DVT/PE and decreased VTE recurrence
VTE in TKR THR
Nonvalvular A Fib

Question 2

Dabigatran Onset and Storage

Answer 2

~2 hours

Store in original container and use within 4 months of opening

Question 3

Dabigatran SE and Age Cut off

Answer 3

> 80 = increased risk for bleeding

SE: dyspepsia (main reason people don’t like it) and bleeding

Question 4

Does Dabigatran have to be dose adjusted?

Answer 4

Yes renal and P-gb inhibitors

Question 5

What are P-gb inhibitors

Answer 5

Ketaconazole
Verapamil
Amiodarone

Question 6

Warfarin → Dabigatran

Answer 6

D/c warfarin

Start dabigatran when INR is less than 2

Question 7

Dabigatran → Warfarin

Answer 7

Initiate warfarin before d/c dabigatran
• 3 days before if CrCl is > 50 ml/min
• 2 days before if CrCl is 31-50 ml/min
• 1 day before if CrCl is 15-30 ml/min

Question 8

IV Anticoagulants → Dabigatran

Answer 8

Initiate less than 2 hours prior to time of next dose or at the time of d/c if continuous infusion

Question 9

Dabigatran → IV Anticoag

Answer 9

• CrCl ≥ 30ml/min  initiate 12 hours after last dose of dabigatran
• CrCl

Question 10

Rivaroxaban Dosing is based on

Answer 10

Indication and Renal Function

Question 11

Rivaroxaban + Non-Valvular A Fib

Answer 11

20 mg

Cut off: less than 15 mL/min

Question 12

Rivaroxaban + DVT/PE

Answer 12

15 mg BID x 3 weeks then 20 mg daily

Cut off: less than 30 mL/min

Question 13

Rivaroxaban + DVT in Hip/Knee Replacement

Answer 13

10 mg daily

Cut off: less than 30 mL/min

Question 14

Rivaroxaban + DVT/PE Secondary Prevention

Answer 14

20 mg daily

Cut off: less than 30 mL/min

Question 15

Rivaroxaban Special Considerations

Answer 15

Take with food to improve absorption

Can be crushed

Question 16

Rivaroxaban DDI

Answer 16

CYP3A4 and P-gp

Question 17

Warfarin → Rivaroxaban

Answer 17

D/c warfarin

Start R when INR is less than 3

Question 18

Rivaroxaban → Warfarin

Answer 18

Start warfarin and IV anticoagulant 24 hours after d/c R

Question 19

IV Anticoag → Rivaroxaban

Answer 19

Less than 2 hours prior to next dose or at the time you d/c continuous infusion

Question 20

Rivaroxaban → IV Anticoag

Answer 20

At time of next dose

Question 21

Apixaban Dosing based on

Answer 21

Indication and patient characteristics

Question 22

Apixaban + Non-valvular A Fib

Answer 22

5 mg BID

Question 23

Apixaban + DVT/PE

Answer 23

10 mg BID x 7 days, then 5 mg BID

Question 24

Apixaban + DVT Hip/Knee Replacement

Answer 24

2.5 mg BID
Hip x 35 days
Knee x 12 days

Question 25

Apixaban + Secondary Prevention of DVT/PE

Answer 25

2.5 mg BID after at least 6 months of VTE treatment

Question 26

Apixaban Special consideration

Answer 26

Not affected by food

Avoid if moderate to severe hepatic insufficiency or CrCl less than 15 mL/min

Question 27

Apixaban DDI

Answer 27

CYP3A4 and P-gp inhibitors = reduce apixaban by 50%

Question 28

Warfarin → Apixaban

Answer 28

D/c warfarin, initiate apixaban when INR less than 2

Question 29

Apixaban → Warfarin

Answer 29

Begin warfarin and IV anticoagulant at next apixaban dose

Question 30

IV Anticoag → Apixaban

Answer 30

D/c IV anticoag, begin apixaban at next dose

Question 31

Apixaban → IV Anticoag

Answer 31

D/c apixaban begin IV anticoag at next dose

Question 32

Edoxaban Dosing based on

Answer 32

Renal function and patient characteristics

Question 33

Edoxaban + Non-valvular A Fib

Answer 33

60 mg daily

Cut off: >95 mL/min or less than 15 mL/min

Question 34

Edoxaban + DVT/PE

Answer 34

60 mg daily after 5-10 days of IV anticoag

Cut off: less than 15 mL/min

Question 35

Edoxaban Special Considerations

Answer 35

Food does not affect absorption

Renally excreted

Question 36

Edoxaban DDI

Answer 36

 Dose decrease to 30 mg daily with P-gp inhibitors (verapamil, quinidine, azithromycin, clarithromycin, erythromycin, itraconazole or ketoconazole oral)

Question 37

Warfarin → Edoxaban

Answer 37

D/c warfarin, initiate when INR is less than 2.5

Question 38

Edoxaban → Warfarin

Answer 38

60 mg daily → reduce to 30 mg daily and begin warfarin
30 mg daily → reduce to 15 mg daily and begin warfarin
D/c E when INR >/= 2 (weekly checks)

D/c IV edoxaban and begin warfarin and IV anticoag at next dose

Question 39

IV anticoag → Edoxaban

Answer 39

Initiate 4 hours after d/c continuous or at time of next LMWH dose

Question 40

Edoxaban → IV anticoag

Answer 40

Initiate at next dose