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OU Module Cardio Spring 2018 > Therapeutics of Venous Vascular Diseases > Flashcards

Therapeutics of Venous Vascular Diseases Flashcards

1
Q

UFH contraindication

A
  • History of HIT
  • Hypersensitivity to agent
  • Active bleeding
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2
Q

LMWH contraindication

A
  • History of HIT
  • Hypersensitivity to agent
  • Active bleeding
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3
Q

FONDAPARINUX contraindication

A
  • CrCl < 30 mL/min (severe renal dysfunction)
  • Fondaparinux-induced thrombocytopenia
  • Hypersensitivity
  • Active bleeding
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4
Q

Warfarin contraindication

A
  • Hypersensitivity to warfarin
  • Active bleeding, Pregnancy category X
  • h/o warfarin-induced skin necrosis or purple toe syndrome
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5
Q

Dabigatran contraindication

A
  • Hypersensitivity

- Active bleeding

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6
Q

Factor Xa inhibitors contraindication

A
  • Hypersensitivity

- Active bleeding

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7
Q

Contraindications in general to VTE treatment

A
  • active bleeding
  • hemophilia
  • severely uncontrolled hypertension (will increase risk for hemorrhagic stroke)
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8
Q

HAS BLED

A
  • Hypertension; esp uncontrolled, at risk for brain bleed
  • Abnormal renal or hepatic function; will also throw off PK of anticoags
  • Stroke (history of)
  • Bleeding, history of
  • Labile International
  • Normalized Ratio (INR) on warfarin therapy
  • Elderly (e.g.> 65 years)
  • Drugs (e.g. concurrent aspirin, nonsteroidal anti-inflammatory drugs (NSAIDS), or heavy alcohol use)
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9
Q

UFH adverse effects

A
  • Bleeding (also bruising at injection site)
  • Osteoporosis (long-term)
  • Thrombocytopenia (mild & severe)
  • Mild: platelet count <150k, goes away within a few days, can change med to make sure it’s not HIT
  • Severe: HIT, platelets & antibodies, platelet count <100K or drop >50%, requires acute attention, D/C med right away
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10
Q

LMWH adverse effects

A
  • Bleeding (but < UFH)
  • Epidural or spinal hematoma
  • HIT (but < UFH)
  • D/C med if there’s too much anticoagulation
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11
Q

FONDAPARINUX adverse effects

A
  • Anemia
  • Bleeding
  • Mild thrombocytopenia (not HIT)
  • D/C med if there’s too much anticoagulation
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12
Q

Warfarin adverse effects

A
  • Bleeding; most common is GI bleed
  • Intracranial hemorrhage
  • Purple toe syndrome
  • Warfarin-induced skin necrosis
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13
Q

Dabigatran adverse effects

A
  • Bleeding (fewer ICH, more GI)
  • Spinal Hematoma
  • Dyspepsia
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14
Q

Factor Xa inhibitors adverse effects

A
  • Bleeding (fewer ICH, more GI)

- Spinal Hematoma

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15
Q

UFH reversal agent

A

Protamine sulfate

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16
Q

LMWH reversal agent

A

Protamine sulfate

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17
Q

FONDAPARINUX reversal agent

A

None

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18
Q

Warfarin reversal agent

A

Vitamin K

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19
Q

Dabigatran reversal agent

A

Idarucizumab (Praxbind ®)

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20
Q

Factor Xa inhibitors reversal agent

A

Currently under investigation but none developed at this time

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21
Q

initial and maintenance dosing principles of warfarin therapy

A
  • Start at 5-10 mg for first 1-2 days
  • Lower starting dose (i.e. < 5 mg, 2-2.5mg) may be appropriate e.g. elderly (over 65), malnourished, congestive heart failure (CHF), liver disease, concomitant drugs, and “sensitive” genetic genotype/variants
  • Steady state should be achieved within 14 days
  • Adjustments made by calculating the weekly dose and ↑ or ↓ by 5-20%
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22
Q

warfarin interactions

A
  • Vit K rich foods
  • chewing tobacco
  • MVI
  • herbals
  • cranberry juice in high consumptions
  • drugs
  • disease
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23
Q

warfarin interactions: drugs

A
  • NSAIDS, aspirin, clopidogrel, DOACs: can increase bleeding risk
  • Cholestyramine: will bind to warfarin and prevent it from being absorbed
  • Increase INR: Acute alcohol use, amiodarone, celecoxib, cimetidine, fluconazole, fluoroquinolones, macrolides, metronidazole, omeprazole, simvastatin, trimethoprim/sulfamethoxazole
  • Decrease INR: Azathioprine, carbamazepine, rifampin, smoking
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24
Q

warfarin interactions: disease

A
  • CHF
  • Diarrhea
  • Vomiting
  • Fever
  • Hepatic disorders
  • Hypo/hyperthyroidism (hypo decreases INR)
  • Poor nutritional state
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25
Q

What to do pre-surgery if pt has to hold warfarin?

A
  • Stop INR for 5 days -> INR should go down to 1

- Can bridge with parenteral anticoag if necessary

26
Q

What to do post-surgery if pt held warfarin?

A
  • Resume both once hemostasis reestablished

- D/C parenteral once INR is reached

27
Q

How do you know when to bridge a patient?

A
  • Bridge: if VTE happened < 3 months or has severe thrombophilia
  • Either/Or: VTE within 3-12 months or non severe thrombophilia
  • No bridge: single VTE > 12 months ago
28
Q

reversal regimen for warfarin

A
  • Oral – 5mg; reassess in 24-48 hours
  • IV – administer 1mg/min max; reassess in 6-12 hours
  • SubQ – not recommended
  • In doses ≥ 10mg, prolonged warfarin resistance may occur
29
Q

What are the ACCP Guidelines when INR > goal < 4.5 and no bleeding?

A

Lower or hold next dose & restart at lower dose

30
Q

What are the ACCP Guidelines when INR 4.5-10 and no significant bleeding?

A

Hold 1-2 warfarin doses

31
Q

What are the ACCP Guidelines when INR > 10 and no significant bleeding?

A

Hold warfarin PLUS Vitamin K PO 2.5-5 mg

32
Q

What are the ACCP Guidelines when Serious or life-threatening bleeding & elevated INR?

A

Hold warfarin, Vitamin K IV 510mg, PLUS FFP or PCC

33
Q

anticoagulants that can be used in a patient with several renal dysfunction

A
  • Can use Enoxaparin but dosing interval has to go from q12 to q24 hours
  • Apixaban
  • Edoxaban can be used in CrCl of 15-95 ml/min
  • Betrixaban can be used in CrCl 15-30 ml/min at 40mg daily with food
34
Q

FONDAPARINUX monitoring

A
  • Therapeutic monitoring not required
  • If needed, can measure anti-Xa levels
  • CBC to monitor for anemia
35
Q

Dabigatran monitoring

A
  • Therapeutic monitoring not required
  • Renal function at baseline and every 3-6 months
  • CBC at baseline and at least annually
36
Q

Factor Xa inhibitors monitoring

A
  • Therapeutic monitoring not required
  • Safety monitoring: renal function at baseline and every 3-6 months
  • CBC at baseline and at least annually
  • Can measure anti-Xa activity but will only tell us presence / absence, won’t tell us how much
  • take with evening meal (high fat and high content) to improve absorption, med adherence is important
37
Q

DOACs Disadvantages

A
  • Many subgroups excluded or underrepresented in trials
  • no measureable assay
  • cannot use in renal or liver dysfunction
  • less flexibility of dosing
  • costs more
38
Q

Good candidates for DOAC use

A
  • Pt preference for and willingness to take DOAC
  • No contraindications to DOAC
  • Good organ function
  • No significant drug-drug interactions
  • Highly likely to be adherent with DOAC
  • Ability to afford DOAC on chronic basis
  • Unable to have routine INR monitoring
39
Q

Good candidates for warfarin use

A
  • Pt preference for and willingness to comply with warfarin monitoring
  • History of poor medication adherence
  • Renal and hepatic impairment
  • Other special populations where DOACs haven’t been adequately studied (pediatrics, breastfeeding)
  • Cannot afford DOACs
  • When avoiding drugs that interact with DOACs is not an option for the patient (due to inability to monitor and dose titrate)
40
Q

4 measures for nonpharmacologic prophylaxis

A
  • Early ambulation
  • Intermittent pneumatic compression (IPC)
  • Graduated compression stockings (GCS)
  • Inferior vena cava (IVC) filter
41
Q

What are the criteria for inferior vena cava filter?

A

For patients actively bleeding, has high hypertension, or has contraindications to anticoags

42
Q

UFH prophylaxis dose

A
  • 5000 U SC BID or TID

- TID dosing has shown improved efficacy in some populations over BID dosing

43
Q

LMWH prophylaxis dose

A

30 mg SC q 12 hours or 40 mg SC q 24 hours

44
Q

Dalteparin prophylaxis dose

A

2500 U or 5000 U SC q 24 hours

45
Q

FONDAPARINUX prophylaxis dose

A

2.5 mg SC daily

46
Q

Dabigatran prophylaxis dose

A
  • 110 mg first day, then 220 mg PO daily

- Avoid if CrCl < 30 ml/min or for patients on dialysis

47
Q

Rivaroxaban prophylaxis dose

A

10 mg PO daily

48
Q

Apixaban prophylaxis dose

A

2.5 mg PO daily

49
Q

Betrixaban prophylaxis dose

A
  • 160 mg day 1, then 80 mg daily with food
  • If CrCl 15-30 ml/min, then 40 mg daily with food
  • Not recommended if CrCl < 15 ml/min
  • Specifically for patients in the hospital
50
Q

Enoxaparin treatment dose

A
  • 1 mg/kg subcutaneous (SC) q 12 hours

- If CrCl < 30 ml/min, reduce to 1 mg/kg SC q 24 hours (renal dysfunction)

51
Q

Rivaroxaban treatment dose

A
  • 15 mg PO BID x 21 days, then 20 mg PO daily with food
  • After at least 6 months of initial therapy, can reduce to 10 mg PO daily with food
  • Avoid if CrCl < 30 ml/min
52
Q

Apixaban treatment dose

A
  • 10 mg PO BID x 7 days, then 5 mg PO BID

- After at least 6 months of initial therapy, can reduce to 2.5 mg PO BID

53
Q

Dabigatran treatment dose

A
  • 150 mg PO BID (after 5-10 days of parenteral anticoagulation)
  • Avoid if CrCl < 30 ml/min or for patients on dialysis
54
Q

Edoxaban treatment dose

A
  • 60 mg PO daily (after 5-10 days of parenteral anticoagulation)
  • 30 mg PO daily if CrCl 15-50 ml/min or weight < 60 kg,(after 5-10 days of parenteral)
  • Avoid if CrCl < 15 ml/min or > 95 ml/min
55
Q

UFH monitoring

A
  • aPTT
  • Reagent-specific therapeutic aPTT range corresponding to plasma heparin level of 0.2-0.4 IU/mL
  • Monitor platelet count every other day until day 14 or until UFH discontinued to monitor development of HITT
56
Q

LMWH monitoring

A
  • Therapeutic monitoring not required
  • If needed, can measure anti-Xa levels
  • Special populations: children, pregnancy, weight is < 50 kg or > 155 kg
57
Q

Wafarin monitoring

A
  • Follow-up and INR within 3 days, and then follow-up at least every 3-5 days until INR is within the range of 2.0-3.0 for 2 consecutive readings and patient is on a maintenance dose of warfarin.
  • Assess INR w/in 7-14 days of dose adjustment
  • Assess INR monthly if stable and can extend to every 6-12 weeks if very stable
  • CBC annually for safety monitoring
  • For maintenance: monitor medication adherence, medication changes, bleeding, thrombosis, dietary changes, social habits (i.e. smoking)
58
Q

UFH treatment dosing

A
  • weight based dosing

- every hospital has their own protocol

59
Q

FONDAPARINUX treatment dosing

A
  • < 50 kg = 5 mg SC Q 24 hours
  • 50-100 kg = 7.5 mg SC Q 24 hours
  • > 100 kg = 10 mg SC Q 24 hours
60
Q

How long should therapy of VTE last?

A
  • 3 months: first VTW with reversible or transient factors
  • 3 months to indefinite: first VTE, unprovoked
  • Indefinite: recurrent VTE
61
Q

What is used for prophylaxis?

A
  • UFH
  • LMWH
  • Dalteparin
  • FONDAPARINUX
  • Dabigatran
  • Rivaroxaban
  • Apixaban
  • Betrixaban
62
Q

What is used for treatment?

A
  • Enoxaparin
  • Warfarin
  • Rivaroxaban
  • Apixaban
  • Dabigatran
  • Edoxaban

OU Module Cardio Spring 2018 (16 decks)

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