Side Effects and Dosing Flashcards
Heparin dosing
Prophylaxis VTE dose
5000 units SC q8-12h
Tx of VTE
80 units/kg IV bolus, 18 units/kg/kr infusion
Tx of ACS/STEMI
60 units/kg bolus, infuse 12 units/kg/hr
***use TBW
Heparin SE
CI: active bleed
Warning: FATAL medication errors
SE: bleeding, thrombocytopenia, hyperkalemia, and osteoporosis (long-term)
MONITOR aPTT or anti-Xa 6 hours after initation and every 6 hours until therapeutic
aPTT range 1.2-2.5 x control
Lovenox Dosing
Enoxaparin (LMWH)
Prophylaxis VTE
40 mg SC daily
30 mg SC BID
or CrCl < 30 = 30 mg SC QD
VTE treatment or NTEMI
1 mg/kg SC q12h
CrCl < 30 = 1 mg/kg SC daily
STEMI treatment < 75 years
30 mg bolus + 1mg/kg SC dose + 1 mg/kg SC BID
CrCl: 1 mg/kg SC daily
STEMI treatment >/= 75 years
NO BOLUS, 0.75 mg/kg SC BID
CrCl < 30 1 mg/kg SC daily
Lovenox
BW: neuroaxial ansethesia or spinal puncture are INCREASED risk for hematoma and paralysis
CI: history of HIT, active major bleed
SE: bleeding anemia, injection site rxms, thrombocyopenia
What are some enoxaparin injection counseling points?
- Do NOT expel air out of the syringe… there will be loss of drug!!!
- store at ROOM temperature
-Do NOT rub injection site
HIT
immune mediated IgG reaction where antibodies form against heparin bound platelets creating a complex and has HIGH risk of venous and arterial thrombosis
- induces platelet aggregation = prothrombotic state!!!!!
- defined as unexplained drop in platelet 50% from baseline
Eliquis dosing
Apixaban
Afib (stroke prophylaxis)
5 mg PO BID
*** unless patient has 2 of:
- >/= 80 years old
-body weight </= 60 kg
-SCR 1.5 >/= 1.5
then do 2.5 mg PO BID
Treatment of VTE
Initial 10 mg BID x 7 days
then 5 mg PO BID
Prophylaxis DVT after knee/hip replacement
2.5 mg PO BID for limited time
Xarelto dosing
***doses >/= 15 mg MUST be taken with food!!!!!!
Afib
CrCl > 50 = 20 mg daily with evening meal
CrCl 15-50 = 15 mg daily with evening meal
CrCl < 15 DO NOT USE
Treatment of VTE
Initial: 15 mg PO BID x 21 days
then 20 mg PO daily with evening meal
CrCl < 30 DO NOT USE
Prophylaxis DVT after hip/knee replacement
10 mg PO daily
Reduction in risk of major CVD events in CAD/PAD
2.5 mg PO BID in combo with ASA
Edoxaban dose
Afib
CrCl > 95 mL/min DO NOT USE
Treatment of DVT
start after 5-10 days of parenteral anticoagulation, 60 mg daily
Eliquis, Xarelto
BW: neuraxial anesthesia or spinal puncture have increased risk of hematoma and paralysis
CI: active bleed
Warning: NOT recommended with prosthetic heart valves or antiphospholipid syndrome
SE: bleeding
no monitoring is requires
Antidote: Andexxa
Edoxaban
BW: neuraxial anesthesia or spinal puncture have increased risk of hematoma and paralysis
***avoid use in afib patients with CrCl > 95!!!!!!
CI: active bleed
Warning: NOT recommended with prosthetic heart valves or antiphospholipid syndrome
SE: bleeding, rash, increased LFTs
no monitoring is requires
Fondaparinux SE
BW: neuraxial anesthesia or spinal puncture have increased risk of hematoma and paralysis
CI: active bleed, SEVERE RENAL IMPAIRMENT (CrCl < 30)
SE: bleeding, anemia
Monitor Anti-Xa levels
**NO ANTIDOTE
Pradaxa SE
Dabigatran
BW: neuraxial anesthesia or spinal puncture have increased risk of hematoma and paralysis
CI: active bleed, mechanical heart valve!!!
Warning: NOT recommended in antiphospholipid syndrome
SE: bleeding, dyspepsiam gastritis-like symptoms
no monitoring is requires
Antidote: idarucizumab (Praxband)
**Tybost (Cobicistat) and Stribild or Genvoya (HIV containing cobicistat) can INCREASE exposure to dabigatran (Pradaxa)
Pradaxa dosing
Dabigatran
Afib
150 mg BID
CrCl AVOID
Treatment VTE
150 mg BID, start after 5-10 days of parenteral anticoagulation!!!
Prophylaxis after hip/knee replacement
CrCl < 30 avoid use
Angiomax SE
Bivalirudin
IV Direct Thrombin Inhibitor
**safe with active HIT or history of HIT - preferred with PCI in patients at risk for HIT
SE: bleeding, anemia
NO ANTIDOTE
