Reversal of Oral and Parenteral Antithrombotic agents

Question 1

What is the Max dose of protamine (IV) to reverse Enoxaparin and Dalteparin

Answer 1

50mg

Question 2

1mg of protamine neutralizes approx how many units of IV UFH given in the previous 3 hours

Answer 2

100 units

Question 3

what is the onset of action of protamine to neutralize heparin

Answer 3

5 mins

Question 4

Is there a reversal specific for fondaparinux? what could be given?

Answer 4

NO and no pharmacological antidote

aPCC Do not admin protamine

Question 5

what can you use to reverse Direct Thrombin inhibitors (Argatroban and bivalirudin?)

Answer 5

supportive care which could include: desmoporessin, cryoprecipitate, or antifibrinolytic therapy (aminocaprotic acid)

Question 6

Is there a reversal agent for antiplatelets?

Answer 6

NO

Question 7

for those with intracranial hemorrhage due to antiplatelet when it is appropriate to tx with platelet transfusion?

Answer 7

for those who are about to undergo neurosurgical procedure

Question 8

which antiplatelet reversibly inhibits platelet function

Answer 8

Ticagrelor (Brilinta)

Question 9

what 3 antiplatelets irreversibly inhibits platelet function?

Answer 9

Aspirin, Plavix, effient (prasugrel)

Question 10

how longs dose antiplatelet effects last for the following agents

1. Aspirin
2. Plavix
3. Effient
4. Brillinta

Answer 10

1. 4 days
2. 10 days
3. 5-9 days
4. 5 days

Question 11

Thrombolytic infusions (tPA) should be stopped immediately in any patient with acute changes suggestive of….

Answer 11

intracranial hemorrhage (confirmed by CT)

Question 12

Administer _______ in pts with thrombolytic agent related symptomatic intracranial hemorrhage who have received a thrombolytic agent in the previous 24 hours

Answer 12

Cryoprecipitate

Question 13

In cases where cryoprecipitate is contraindicated for management of thrombolytic associated bleeding you can administer what instead?

Answer 13

Antifibrinolytic (tranexamic acid or aminocaproic acid)

Question 14

what do you admin when pt is on warfarin and has a life threatening bleeding event or emergency surgery

Answer 14

KCENTRA (Weight or INR based dosing)

Question 15

what can you give if Kcentra is contraindicated and pt is on warfarin and has a life threatening bleeding event or emergency surgery

Answer 15

Fresh frozen plasma (FFP)

Question 16

what is the reversal agent for dabigatran and what is the dose?

Answer 16

Praxbind (5g 100ml IV) over 10 mins

Question 17

What can you give if pt has bleeding event while on dabigatran and praxbind is contraindicated?

Answer 17

KCENTRA (50units/kg or 2000 units)

Dialysis removes 60%

Question 18

Which factor Xa inhibitors does andexxa reverse?

Answer 18

Apixaban or Rivaroxaban

Question 19

what is the dose of andexxa for reversal

Answer 19

based off specific anti-Xa inhibitor dose and time since last dose

Question 20

which Factor Xa inhibitor can be reversed by KCENTRA?

Answer 20

Apixaban, rivaroxaban, and edoxaban

Question 21

Elimination of drugs occurs approx after how many 1/2 lives with stable renal and hepatic function?

Answer 21

3-5

Question 22

Anticoag reversal should be limited to serious bleeding where the immediate need for anticoag reversal outweighs the risk of thrombosis and ONLY if what

Answer 22

if bleeding is not controlled with maximal supportive measures

Question 23

what are other interventions that can be made for pts with a bleeding event on an anticoagulation therapy?

Answer 23

Fluid support, blood (RBC), platelet transfusion, mechanical compression, anti-fibronlyic agents, surgical interventions and hemodynamic support.

Question 24

What are the characteristics for a patient to be deemed high bleeding risk?

Answer 24

Increase Scr
GI bleed history 
age greater than 70 
uncontrolled HTN, 
fall risk
dementia