Thromboembolism

Question 1

in what situations would you use unfractionated heparin over LMWH?

Answer 1

1. renal impairment
2. in patients you want to reverse the effects/have short action (unfractionated heparin has shorter half life)

Question 2

what anticoagulant is used in surgery for patients with lower limb immobilisation or pelvis fragility fractures?
what drug class is it?

Answer 2

fondaparinux

Xa inhibitor

Question 3

how long in VTE prophylaxis in surgery?
what if major cancer surgery in abdomen?
what if spinal surgery?

Answer 3

• at least 7 days post surgery or until sufficent mobility
• major cancer in abdomen = 28 days
• spinal surgery = 30 days

Question 4

what are the 3 VTE prophlyaxis plans for elective hip replacement surgery?

Answer 4

1. LMWH for 10 days then 75mg aspirin for 28 days
2. LMWH for 28 days + stockings until discharge
3. Rivaroxaban

Question 5

what are the 3 VTE prophlyaxis plans for elective knee replacement surgery?

Answer 5

1. 75mg aspirin for 14 days
2. LMWH for 14 days + stockings until discharge
3. Rivaroxaban

Question 6

are all pregnant women given VTE prophylaxis?

Answer 6

no - only those who are high risk

Question 7

what VTE prophylaxis is given to women who have just given birth, had a miscarrige or termination of pregnancy in the past 6 weeks?

Answer 7

LMWH 6 - 8 hours after the event - contiune for minimum of 7 days

Question 8

what 2 Xa inhibitors can be given for confirmed DVT/PE?

Answer 8

rivaroxaban or apixiabn

Question 9

if rivaroxaban or apixaban are unsuitable what are the 2 alternative plans?

Answer 9

1. LMWH for 5d followed by dabigatran or edoxaban
2. LMWH + warfarin for at least 5 days or until INR is at least 2.0 for 2 consecutive readings followed by warfarin alone

Question 10

how long is the treatment for distal DVT (calf)?

Answer 10

6 weeks

Question 11

how long is the treatment for proximal DVT/PE?

Answer 11

at least 3 months (3 - 6 months in those with active cancer)

Question 12

how long is the treatment for provoked DVT/PE?

Answer 12

stop at 3 months if provoking factor resolved

Question 13

how long is the treatment for unprovoked DVT/PE?

Answer 13

3 months +

Question 14

how long is the treatment for recurrent DVT/PE?

Answer 14

long term

Question 15

in what situations do you aim for INR of 2.5 (+/- 0.5)?

Answer 15

VTEs, AF, cardioversion, MI, cardiomyopathy

Question 16

in what situations do you aim for INR 3.5 (+/- 0.5)?

Answer 16

recurrent VTEs, or mechanical heart valves

Question 17

what do you do if someone on warfarin has a major bleed?

Answer 17

stop warfarin
IV phytomenadione
dried prothrombin

Question 18

what do you do with someone on warfarin has a minor bleed and INR >8?

Answer 18

stop warfarin
IV phytomenadione

Question 19

what do you do with someone on warfarin has no bleeding but INR >8?

Answer 19

stop warfarin
PO phytomenadione

Question 20

what do you do with someone on warfarin has bleeding and INR 5 - 8?

Answer 20

stop warfarin
IV phytomenadione

Question 21

what do you do with someone on warfarin has no bleeding but INR 5 - 8?

Answer 21

with hold 1 - 2 doses of warfarin

Question 22

when can you restart warfarin after someone has has a bleed/raised INR?

Answer 22

when INR less than 5

Question 23

how does INR need to monitored in someone on warfarin?

Answer 23

every 1 - 2 days in early treatment
then every 12 weeks

Question 24

whats the MHRA warning for warfarin?

Answer 24

skin necrosis and calciphylaxis (painful skin rash)

Question 25

what vitamin is phytomenadione?

Answer 25

K1

Question 26

can warfarin be used in pregnancy?

Answer 26

avoid in 1st and 3rd trimester as teratogenic
need contraception

Question 27

what 4 interactions do you need to look out for with warfarin?

Answer 27

1. vitamin K rich foods - these reduce the efficacy of warfarin (leafy greens)
2. pomegranate and cranberry juice - increases INR
3. Miconazole - increases INR
4. CYP inducers/inhibitors

Question 28

when do you need to stop and restart warfarin in minor surgery?

Answer 28

• surgery performed with and INR less than 2.5
• restart warfarin within 24 hours of procedure