VTE Flashcards
UFH dose for VTE prophylaxis
5000 units sq q8h
UFH contraindications
history of HIT
when is UFH preferred
its lack of renal clearance makes it ideal for patients with AKI or CrCL <30 mL/min
enoxaparin dose for VTE prophylaxis
40 mg sq q24h or 30 mg sq q12h
renal dose adjustment enoxaparin for VTE prophylaxis
30 mg sq q24h
enoxaparin contraindications
AKI, HIT
dalteparin VTE prophylaxis dose
5000 units sq q24h
dalteparin contraindications
AKI, HIT
fondaparinux VTE prophylaxis dose
2.5 mg sq q24h
fondaparinux contraindications
CrCL <30 mL/min
when is fondaparinux preferred
patient with history of HIT
apixaban VTE prophylaxis dose for total hip arthroplasty
2.5 mg bid x 35 days
apixaban VTE prophylaxis dose for total knee arthroplasty
2.5 mg bid x 14 days
dabigatran VTE prophylaxis dose for total hip arthroplasty
110 mg once, then 220 mg daily x 35 days
rivaroxaban VTE prophylaxis dose in acute medical illness or total hip arthroplasty
10 mg daily x 35 days
rivaroxaban VTE prophylaxis dose for total knee arthroplasty
10 mg daily x 14 days
instances to avoid DOACs for VTE treatment
renal insufficiency, moderate to severe liver disease, significant drug-drug interactions (CYP3A4 inducers), CrCL < 30 mL/min)
apixaban dose for VTE treatment
10 mg bid x 7 days, then 5 mg bid x 3-6 months
dabigatran dose for VTE treatment
> 5 days of parenteral anticoagulation, then 150 mg bid x 3-6 months
edoxaban dose for VTE treatment
> 5 days of parenteral anticoagulation, then 60 mg daily x 3-6 months
rivaroxaban dose for VTE treatment
15 mg bid x 21 days, then 20 mg daily x 3-6 months
which DOACs require parenteral anticoagulation first for VTE treatment
dabigatran and edoxaban
UFH dose for VTE treatment
80 units/kg IV bolus, then 18 units/kg/hr initial rate titrated to aPTT or anti-Xa
enoxaparin dose for VTE treatment
1 mg/kg q12h (reduced to q24h if CrCL<30 mL/min)
dalteparin dose for VTE treatment
100 units/kg q12h
fondaparinux dose for VTE treatment, <50 kg
5 mg daily
fondaparinux dose for VTE treatment, 50-100 kg
7.5 mg daily
fondaparinux dose for VTE treatment, >100 kg
10 mg daily
which DOAC must be taken with food to facilitate absorption
rivaroxaban
____ is the risk calculator used for medical patients
padua score
____ is the risk calculator used for surgical patients
caprini score
non-pharm VTE prophylaxis options
early ambulation, graduated compression stockings, intermittent pneumatic compression device, inferior vena cava (IVC) filters
for high bleed risk patients, use ____ prophylaxis
mechanical
when using pharm VTE prophylaxis, opt for ___
low dose
for medical patients when pharm prophylaxis is used, ____ is preferred
LMWH
for orthopedic surgery patients when pharm prophylaxis is used, _____ is preferred
DOAC
for other major surgery patients when pharm prophylaxis is used, _____ is preferred
UFH or LMWH
lab findings in DVT diagnosis
D-dimer elevation
D-dimer is a product of _____
fibrin degradation
non-invasive testing for DVT diagnosis
doppler ultrasonography
invasive testing for DVT diagnosis
contrast venography
lab findings in PE diagnosis
d-dimer elevation
other ways to diagnose PE
ECG, chest xray, echo
invasive testing for PE diagnosis
CT pulmonary angiography, ventilation/perfusion scan
PE subtypes describe ____
the effect on the body, not the size of the clot
massive PE
high risk, hemodynamic compromise, hypotension (SBP <90), may be candidates for thrombolytic therapy
submassive PE
intermediate risk, without hemodynamic stability, evidence of right ventricular strain, positive cardiac biomarkers (troponin, BNP)
non-massive PE
low risk
for uncomplicated DVT and low-risk PE, what is preferred
outpatient, DOAC
good DOAC candidates
clinically stable, CrCL>30 mL/min, no drug-drug interactions
not good DOAC candidates
renal insufficiency, moderate to severe liver disease, significant drug interactions (CYP3A4 inducers)
for limb-threatening DVT and intermediate to high risk PE, _____ is preferred
hospital admission and parenteral therapy
advantages for DOACs in VTE
avoids parenteral therapy, predictable PK/PD effects, fixed dosing, similar or better efficacy with less major bleeding
how to bridge to warfarin from parenteral anticoagulation
bridge until INR >2 on 2 consecutive readings 24 hours apart, minimum total overlap of 5 days
how to bridge to DOAC from UFH
may discontinue infusion and give oral med simultaneously
how to bridge to DOAC from LMWH or fondaparinux
give the oral dose when the next injection would have been due
when is warfarin actually preferred
patients with renal insufficiency or antiphospholipid antibody syndromes
why does warfarin have a delayed anticoagulation effect
it doesn’t influence existing clotting factors, its onset is limited by decreased production of new clotting factors
things to note when using warfarin for VTE
frequent monitoring is required, goal INR 2-3 for most, drug/food interactions influence dose
VTE treatment duration
3-6 months unprovoked, indefinite for unprovoked
apixaban dose for ongoing secondary prevention/risk reduction
2.5 mg bid
rivaroxaban dose for secondary prevention/risk reduction
10 mg daily
