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Cardio-Renal I Midterm > Therapeutics - VTE Part 2 > Flashcards

Therapeutics - VTE Part 2 Flashcards

1
Q

LMWH can be used for VTE treatment for initial AND long term therapy

however, long term use is reserved for who?

A

pts who can’t take warfarin or have cancer

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2
Q

which is more predictable and why - heparin or LMWH

A

LMWH

less protein binding so better PK profile

it’s better clinically - less deaths and hemorrhages and recurrent VTE

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3
Q

true or false

clearance of LMWH is dependent on kidney function

A

TRUE

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4
Q

where is LMWH like enoxaparin injected

A

available as prefilled syringes or multi dose vials

injected into abdominal area aorund the belly button or the outer upper thigh

rotate injection sites!

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5
Q

how does the dose of enoxaparin change for kidney function

A

normal - 1mg/kg subq q 12 or 1,,5mg/kg subq qd

BUT if crcl less than 30 - do 1mg/kg qd

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6
Q

true or false

there is no kidney concern with dalteparin and tinzeparin

A

FALS

they are LMWH —- if cr cl less than 30, need to be cautious and consider reducing dose

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7
Q

how are dalteparin and tinzeparin administered

A

subq

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8
Q

true or false

it is not routine to monitor efficacy when treating VTE with LMWH

A

true

may check anti xa activity only in renal disease or pregnancy

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9
Q

BBW enoxaparin and LMWH

A

same as fondaparinux –spinal hematoma after lumbar puncture, epidural, etc

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10
Q

the AE of LMWH is similar to….

A

heparin

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11
Q

true or false

LMWH has a lower risk of developing osteoporosis than heparin

A

true

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12
Q

true or false

protamine can be used to reverse LMWH

A

FALSE

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13
Q

**cost of heparin vs LMWH

A

the drug itself — enoxaparin is more expensive BUT if getting heparin you need to stay in hospital - potential cost more – requires tubing and infusion pump and a nurse

whereas LMWH given once or twice a day by YOURSELF in prefilled syringes

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14
Q

**differentiate between the monitoring of LMWH vs heparin for treating VTE

A

heparin - have to monitor the aPTT frequently until reaches therapeutic range, and then monitor daily

LMWH - no monitoring necessary, only rare occassions

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15
Q

**differentiate between the reversal agent for heparin vs LMWH

A

heparin has protamine, LMWH does not have one

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16
Q

*differentiate between the half lives of LMWH vs heparin and is this is advantage/disadvantage

A

heparin has shorter half life. this is good bc we can turn it off if procedure or bleed is suspected, however it does need continuous drip

LMWH has longer half life which is bad bc we can’t quickly stop it, however, it can be administered once or twice at home

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17
Q

***true or false

LMWH has lower HIT and osteoporosis than heparin

A

true

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18
Q

can fondaparinux be reversed

A

no

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19
Q

checking for target aPTT for heparin is every….

A

6 hours! - thats a lott use nomogram to help!

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20
Q

differentiate between HIT type 1 and HIT type 2:

-immune mediated?
reversible?
occurs quickly or over 5-14 days?

platelet count?

symptoms?

MANAGEMENT?

A

HIT typ1 is non immune, reversible, platelets below 100k, occurs quick, and is asymptomatic. NO management needed

HIT typ 2 is immune mediated and has long onset, platelets decrease below 50% and there is high risk of clot. management is to stop the heparin, start a direct thrombin inhibitor, and document the allergy

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21
Q

there is higher risk of HIT type 2 when it is administered what route?

A

IV is higher risk than subq

also, heparin has higher risk than UFH

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22
Q

name 3 intravenous direct thrombin inhibitors

they are used as alternative anticoagulants in _____

A

argatroban, lepirudin, bivalirudin

HIT

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23
Q

bridging to warfarin with an IV direct thrombin inhibitor

A

it’s hard bc they all increase the INR

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24
Q

for which IV direct thrombin inhibitor do we reduce the dose for hepatic dysfuncion? what about renal?

A

renal - lepirudin and bivalirudin

hepatic - argatroban

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25
Q

3 reasons why bridging is necessary when we want to start warfarin to treat VTE

A

has longgggg half life. need to give parenteral anticoagulant first

need to get to the anticoagulated state quickly – cant wait long when the pt has a dangerous clot

clotting factors have a long half (last long time) and our endogenous anticoagulants have a short one! – pts are in hypercoaguable state

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26
Q

true or false

when using bridge therapy to treat VTE, warfarin is started on day 1 with the parenteral therapy

A

TRUE

parenteral is then continued for 5 or more days AND until the INR is 2 or more

27
Q

monitoring for warfarin - how often:

-inpatient?
-outpatient?
-how is the dose calculated?

A

inpatient - daily

outpatient - every few days after first starting, then eventually every 4-6 weeks when the pt is stable

dose is calculated GENTLY - total weekly dose is increased or decreased by 10-15% depending on results

28
Q

important note when monitoring iNR

A

it lags! takes days to see the effect

29
Q

NORMAL aptt

A

around 25-30 secs

30
Q

3 AE of warfarin

A

hemorrhge

skin necrosis (rare)

purple toe syndrome (rare)

31
Q

the bleeding/hemorrhage risk for warfarin is strongly related to….

A

the INR value! need to watch very closely

32
Q

how can rare skin necrosis from warfarin be avoided

A

by bridging with parenteral

if it happens tho - need to stop the warfarin

same w purple toe syndrome

33
Q

large doses of vitamin K can cause….

A

prolonged resistance to warfarin

34
Q

general management of overanticoagulation from warfarin

A

can give vitamin K, blood, cfresh frozen plasma, or factor concentrates (but short half life)

35
Q

is vitamin K administered IM? sub q? iv? po?

A

IM - CONTRAINDICATED

subq - unrelaible absorption

IV - does correct the INR within 24 hours, but there’s potential for anaphylaxis — have to dilute and administer SLOW

PO - corrects the INR in 1-2 days

36
Q

INR less than 5 what is recommendation

A

lower or hold the dose

37
Q

INR is 5-8.9 what is recommendation

A

hold 1 or 2 doses of warfarin

can consider giving vitamin K less than 5mg PO

38
Q

INR is 9 or more what is recommendation

A

hold the warfarin, and give vitamin K 5-10mg po

39
Q

if the INR is so high OR there is serious bleeding, what is recommendation

A

hold warfarin, give vitamin K 10mg IV + factor replacement

40
Q

when giving warfarin, it’s so important to counsel patients on what

A

many factors can affect the INR

-vitamin K intake
-ethanol will elevate
-diarrhea, hepatic disease, heart failure, etc
-genetics in CYP2C9 and VKOR

41
Q

_________ is a contraindication to giving warfarin

A

NONADHERENCE

patient understanding and willingness to monitor are so necessary

42
Q

true or false

all DOACs are renally eliminated

A

FALSE - all except apixaban

43
Q

true or false

for DOACS, there is required, routine anticoagulation monitring

A

FALSE - not necessary

44
Q

2 boxed warnings for DOACs

A

-spinal hematoma
0increased thrombotic events if early discontinuation

45
Q

dabigatran can be used to treat VTE

explain place in therapy

A

there is NOT BRIDGE

given AFTER 5-10 days of parenteral therapy - NO OVERLAP

46
Q

dabigatran dose for treating VTE

A

150mg PO BID

47
Q

storage and expiration counseling pts dabigatran

A

store in ORIGINAL container (NO PILL BOXES) and expires 4 months after opening!

48
Q

do you have to monitor the coagulation panel when using dabigatran to treat VTE

A

NO

may affect it, but not needed to adjust dose

49
Q

reversal agent for dabigatran

A

idarucizumab (praxbind)

50
Q

2 AE dabigatran

A

hemorrhage and GI events

51
Q

true or false

xarelto can be used in bridge therapy to treat VTE

A

FALSE

used AFTER parenteral therapy

15mg BID for 3 weeks with food, then 20mg PO daily with food

52
Q

true or false

xarelto is on the beers list

A

TRUE

avoid in older adults

53
Q

dose eliquis

A

10mg PO BID for 7 days, then 5 mg PO

if using for extended therapy, 2.5mg PO BID

54
Q

Xa inhibitor (ie - eliquis, xarelto) reversal agent

A

andexanet (andexxa)

bolus, then IV infusion but LOT of money

55
Q

true or false

edoxaban is NOT part of bridged therapy

A

true

given AFTER 5-`0 days of parenteral therapy

56
Q

differentiate between the monitoring for DOACs vs warfarin

A

DOACS need NO routine monitoring (tho the labs are affected if checked)

warfarin - need routine INR monitoring - that’s how you find dose!

57
Q

true or false

for most doacs, there is no effective reversal agent available

A

true

58
Q

true or false

for warfarin, there is no effective reversal agent available

A

FALSE - there is

vitamin K, frozen plasma, prothrombin complex concentrate

59
Q

differentiate between the onset and elimination of DOACS vs warfarin

A

DOACS - quick onset and quick elimination

warfarin - long onset and long elimination – that’s why it needs bridge!!

60
Q

differentiate between the DDI of DOACS and warfarin

A

DOACS - just some ddi

warfarin - HUNDRES of DDI

61
Q

AE and efficacy of DOACs vs warfarin

A

both are relatively the same, except that apixaban has less bleeding concern

62
Q

name a drug that is only used then PE is so severe that you need to clear ASAP

A

alteplase - a thrombolytic - ONLY given once

63
Q

true or false

patients need to have consistent vitamin K intake for warfarin to work

A

true! dont change randomly tho - just take normal, recommended amount in your diet

64
Q
A

Cardio-Renal I Midterm (14 decks)

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