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7442 Cardio Test 3 > VTE > Flashcards

VTE Flashcards

1
Q

enoxaparin (VTE prophylaxis general medical pts)

Dose?

A

dose: 40mg SQ QD

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2
Q

dalteparin (VTE prophylaxis general medical pts)

Dose?

A

5,000 units SQ QD

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3
Q

UFH (VTE prophylaxis general medical pts)

dose?

A

5,000 units SQ Q8h or Q12h

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4
Q

fondaparinux (VTE prophylaxis general medical pts)

dose?

A

2.5mg SQ QD

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5
Q

betrixaban (VTE prophylaxis general medical pts)

dose?

A

160mg PO x 1 dose, then 80mg PO QD for 35-42 days

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6
Q

What is preferred for VTE prophylaxis in orthopedic surgical pts?

A

LMWH

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7
Q

Apixaban (VTE prophylaxis in orthopedic surgical pts)

dose?

A

2.5mg PO BID

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8
Q

rivaroxaban (VTE prophylaxis in orthopedic surgical pts)

dose?

A

10mg PO QD

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9
Q

dabigatran (VTE prophylaxis in orthopedic surgical pts)

dose?

A

110mg PO on day of surgery, followed by 220 mg PO QD

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10
Q

Duration of provoked VTE Tx?

A

3 months

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11
Q

apixaban VTE Tx dosing regimen?

A

10mg PO BIX x 7 days, then 5mg PO BID, then option to reduce to 2.5mg PO BID after 1st 6 months

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12
Q

rivaroxaban VTE Tx dosing regimen?

A

15mg PO BID x 21 days, then 20mg PO QD, then option to reduce to 10mg PO QD after 1st 6 months

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13
Q

dabigatran VTE Tx dosing regimen?

A

first 5 days parenteral UFH, LMWH, fondaparinux (all SQ), then switch to 150mg PO BID dabigatran

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14
Q

Edoxaban VTE Tx dosing regimen?

A

first 5 days parenteral UFH, LMWH, fondaparinux (all SQ), then switch to 60mg PO daily Edoxaban

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15
Q

warfarin VTE Tx dosing regimen?

A

at least 1st 5 days UFH, LMWH, fondaparinux (all SQ), overlapped with warfarin PO QD AND INR >=2.0, then dose adjusted to INR 2.5

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16
Q

Parenteral anticoagulants:

What does UFH inhibit?

A

factor Xa dn thrombin (IIa) in a 1:1 ratio

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17
Q

Parenteral anticoagulants:

What does LMWH inhibit?

A

factor Xa and thrombin (IIa) in 3:1 ratio

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18
Q

Parenteral anticoagulants:

What does fondaparinux inhibit?

A

factor Xa (not thrombin)

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19
Q

UFH continuous IV infusion initial dosing?

A

80 units/kg bolus (max 10,000 Units) IV, followed by 18 units/kg/hr (max 2,000 units/hr)

adjust based on institution-specific heparin infusion nomogram

SQ not preferred

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20
Q

UFH SQ dosing?

A

333 units/kg bolus SQ, followed by 250 units/kg SQ Q12hr

not preferred

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21
Q

What aPTT results in no change to heparin dosing?

A

50-55

take next aPTT 6hrs after previous aPTT

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22
Q

UFH highlighted AE?

A

thrombocytopenia (HIT)

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23
Q

enoxaparin VTE Tx dose?

A

1mg/kg BID or 1.5 mg/kg SQ daily

syringes: 30, 40, 60, 80, 100, 120, 150 mg/mL available

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24
Q

dalteparin VTE Tx dose?

A

100 units/kg SQ BID or 200 units/kg SQ daily

refilled syringes: 2500, 5000, 7500, 10000, 12500, 15000, 18000 units/xmL

avoid with CrCl < 30 mL/min

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25
Q

fondaparinux VTE dose?

A

<50kg: 5mg SQ daily
50-100kg: 7.5mg SQ daily
>100kg: 10mg SQ daily

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26
Q

Reduce fondaparinux (VTE Tx) by how much with CrCl 30-50?

A

50%

CrCl < 30 avoid using

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27
Q

heparin induced thrombocytopenia (HIT) is what PLT count?

A

< 100 x 10^9/L

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28
Q

heparin induced thrombocytopenia (HIT) is what PLT reduction?

A

> 50% reduction from baseline

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29
Q

What score represents low probability for HIT?

A

< 3

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30
Q

What score represents intermediate probability for HIT?

A

4-5

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31
Q

What score represents high probability for HIT?

A

> 6

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32
Q

Parenteral anticoagulation monitoring:

check platelets when?

A

baseline and every 2-3 days between days 4-14 or until UFH/LMH d/c

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33
Q

What factor Xa inhibitor is not indicated for VTE Tx?

A

betrixaban

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34
Q

rivaroxaban VTE Tx dosing?

A

Initiation: 15mg PO BID x 21 days
Maintenance: 20mg PO daily
Extended: option to reduce to 10mg PO daily after 6 months

QD dosing avoids parenteral anticoagulation

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35
Q

rivaroxaban atrial fibrillation dosing?

A

20mg PO daily

CrCl 15-50: 15mg PO daily
CrCl < 15: avoid

QD dosing avoids parenteral anticoagulation

36
Q

Take rivaroxaban with or without food?

A

with food to improve absorption

37
Q

Apixaban VTE Tx dosing?

A

initiation: 10mg PO BID x 7 days
maintenance: 5mg PO BID
extended: option to reduce to 2.5mg PO BID after 6 months

BID dosing avoids parenteral anticoagulation

38
Q

Apixaban atrial fibrillation dosing?

A

5mg PO BID

2.5mg PO BID if any 2 of the following: >= 80yo, SCr > 1.5, weight <= 60kg

BID dosing avoids parenteral anticoagulation

39
Q

edoxaban VTE dosing?

A

Initiation: UFH, LMWH, or fondaparinux x 5-10 days

maintenance/extended: 6mg PO daily, or 30mg PO daily if <= 60kg

40
Q

edoxaban atrial fibrillation dosing?

A

60mg PO QD

41
Q

Which DOAC is minimally metabolized by CYP 3A4?

A

edoxaban (Savaysa)

42
Q

dabigatran VTE Tx dosing?

A

initiation: UFH, LMWH, or fondaparinux x 5-10 days

maintenance/extended: 150mg PO BID

43
Q

dabigatran atrial fibrillation dosing?

A

150mg PO BID

44
Q

Which DOACs have interactions with dual strong P-gp and CYP3A4 inducers?

A

rivaroxaban, apixaban

45
Q

Which DOACs have interaction with only P-gp inducers/inhibitors?

A

edoxaban, dabigatran

46
Q

Which DOAC is favored in pts with Hx of GI bleed?

47
Q

Which DOAC causes dyspepsia?

A

dabigatran

48
Q

DOAC contraindications?

A
  • active bleeding

- prosthetic heart valves

49
Q

DOAC limitations (use not recommended)?

A
  • age < 18 yo

- pregnancy/lactation

50
Q

DOAC requirements?

A
  • stable renal fxn

- stable hepatic fxn

51
Q

Pneumonic to remember increasing warfarin tab doses?

A

Please Let Greg Brown Bring Peaches To Your Wedding

pink, lavender, green, brown, blue, peach, teal, yellow, white

52
Q

Warfarin inhibits synthesis of what clotting factors?

A

II, VII, IX, X

SNOT - seven, nine, two, ten

also inhibits synthesis of endogenous anticoagulant proteins C and S

53
Q

VTE Tx: Overlap warfarin with parenteral anticoagulant how long?

A

minimum of 5 days AND until INR > 2.0 for 24hrs

54
Q

warfarin VTE Tx dosing?

A

initial: 5mg PO QD
maintenance: 10mg PO daily x 2 days, then 5mg PO daily
other: 2.5mg PO QD for high risk pts

plus parenteral SQ: UFH, LMWH, fondaparinux

55
Q

INR goal for VTE Tx with warfarin?

56
Q

Warfarin:

INR < 5 with no transient factor identified

A

increase weekly dose 10-20%

consider 1.5-2x supplemental dose

57
Q

warfarin:

INR 1.5-1.7 with no transient factor identified

A

increase weekly dose 5-15%

consider 1.5-2x supplemental dose

58
Q

warfarin:

INR 1.8-1.9 with no transient factor identified

A

if previous 2 INR within range, no explanation for out of range INR, and INR does not represent increased clotting risk consider NO change

otherwise: increase weekly dose 5-105
consider 1.5-2x supplemental dose

59
Q

warfarin:

INR < 1.5
INR 1.5-1.7
INR 1.8-1.9

with transient factor identified

A

consider 1.5-2x supplemental dose, return to previous weekly dose

60
Q

warfarin:

INR 3.1-3.2

no transient factor identified

A

if previous 2 INR within range, no explanation for out of range INR, and INR does not represent increased clotting risk consider NO change

otherwise: decrease weekly dose by 5-10%

61
Q

warfarin:

INR 3.3-3.4

no transient factor identified

A

decrease weekly dose 5-10%

62
Q

warfarin:

INR 3.5-3.9

no transient factor identified

A

decrease weekly dose 5-15%, consider holding 1 dose

63
Q

warfarin:

INR 3.1-3.2
INR 3.3-3.4
INR 3.5-3.9

transient factor identified

A

consider holding 1-2 doses, return to previous weekly dose

64
Q

warfarin:

INR >= 4.0

transient factor and/or no transient factor identified

A

hold until INR < 3.0

decrease weekly dose by 5-20%

if pt high bleeding risk consider low-dose oral vitamin k

check INR every 1-2 days until INR < 3, then q 1-2 weeks

65
Q

warfarin:

Check INR how often in inpatient setting?

A

q 1-3 days

66
Q

warfarin:

outpatient setting in pts who are stable x 3 months check INR how often?

A

q 8-12 weeks

67
Q

What antibiotic decreases warfarin effect?

A

rifampin

decreases INR

68
Q

What analgesic increases warfarin effect?

A

tramadol

increases INR

69
Q

Do antifungals increase or decrease warfarin effect?

A

decrease

fluconazole, ketoconazole, miconazole

70
Q

d/c warfarin how many days before procedure?

A

5

bridge

resume warfarin 12-24hrs after procedure

71
Q

warfarin perioperative management:

bridge if VTE within what time frame?

A

past 3 months

severe hypercoagulable state

72
Q

warfarin perioperative management:

maybe bridge if VTE within what time frame?

A

past 3-12 months

73
Q

warfarin perioperative management:

do NOT bridge if VTE within what time frame?

A

> 12 months ago

74
Q

breastfeeding pts are optimal ___ candidates

DOAC or warfarin

75
Q

Which can be used in renal/hepatic impairment?

DOAC or warfarin

76
Q

UFH dose (VTE prophylaxis) in obesity?

A

7500 units SQ Q8h

no change to VTE TX doses; use actual body weight for Tx doses

77
Q

VTE obesity weight/BMI?

A

> 100kg or BMI > 40

78
Q

Avoid DOACs with what weight/BMI?

A

> 120kg or BMI > 40

or monitor with peak and trough

79
Q

Severe renal impairment CrCl for VTE?

A

AKI, dialysis, or CrCl < 30ml/min

80
Q

What agent is preferred for prophylaxis and acute Tx of VTE in pts with severe renal impairment?

A

UFH

warfarin may also be used; dose adjusted based on INR

81
Q

Avoid what two hirudin derivatives in pts with severe renal impairment?

A

dalteparin, fondaparinux

82
Q

What pregnancy category is warfarin?

A

X

safe in lactation

83
Q

What agent is preferred for VTE Tx in cancer pts?

84
Q

VTE:

What is category 1 mono therapy?

A

dalteparin

85
Q

VTE:

What is category 1 combo therapy?

A

LMWH + edoxaban

7442 Cardio Test 3 (6 decks)

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