VTE formulary Flashcards
Unfractionated heparin bran
UFH
Exonaparin brand
Lovenox
Dalteparin brand
Fragmin
Tinzaparin brand
Innohep
Fondaparinux brand
Arixtra
Rivaroxaban brand
Xarelto
Edoxaban brand
Savaysa
Apixaban brand
Eliquis
Bivalirudin brand
Angiomax
Dabigatran brand
Pradaxa
tPA, Alteplase brand
Activase
Reteplase brand
Retevase
Tenecteplase brand
Tnkase
Urokinase brand
Abbokinase
Warfarin bran
Coumadin, Jantoven
UFH dose
IV or SQ (not IM) Old standard: 5000 u IV bolus + 1000-1200units/hour Subcutaneous: Prophylaxis—5000 u SQ q8-12h (12 if less than 50mL/min CrCl) Treatment—17500 u SQ q12h Weight based (recommended): (80 u)/(kg actual body weight) IV bolus + 18 u/kg/hr inf.
UFH SE
Major bleeding Osteoporosis (if long term) Hypersensitivity HIT HAT
UFH monitoring
aPTT (therapeutic range 1.5-2.5 times normal)
•Baseline
•6 hours after dose or dose change (x24h)
•`Daily after 1st day
Platelet QOD until day 14
lovenox dosing
Prophylaxis: 30mg SQ q12h 40mg SQ daily Treatment: (actual body weight) 1mg/kg SQ q12h 1.5mg/kg SQ daily If CrCl less than 30mL/min: Prophylaxis—30mg SQ daily Treatment—1mg/kg SQ daily
dalteparin dosing
Prophylaxis:
2500-5000 IU SQ daily
Treatment:
200 IU/kg SQ daily (MAX 18000 IU)
tinzaparin dosing
Treatment:
175 anti-Xa IU/kg SQ daily
enoxaparin, dalteparin and tinzaparin SE
Black box warning:
Do NOT use with neural anesthesia/spinal puncture.
Bleeding
Thrombocytopenia (less than UFH)
Delayed HS skin reactions
enoxaparin, dalteparin and tinzaparin monitoring
If CrCl less than 30mL/min (severe kidney failure), children, obesity, long courses, pregnancy, monitor anti-Xa level 4-6h post.
- -BID goal 0.6-1u/mL peak
- -QD goal 0.1-0.3u/mL trough (or 1-2u/mL peak)
Goal 0.5-1.5 in dalteparin less than 30mL/min CrCl.
fondaparinux dosing
Prophylaxis: 2.5mg SQ daily (not for less than 50kg or CrCl less than 30mL/min) Treatment: less than 50kg: 5mg SQ daily 50-100kg: 7.5mg SQ daily over 100kg: 10mg SQ daily
fondaparinux SE
bleeding
fondaparinux monitoring
Can monitor anti-Xa levels, but no routine monitoring
rivaroxaban dosing
DVT prophylaxis: (6-10h post surgery)
10mg PO daily for 35 days in THA, 12 dahs TKA
DVT/PE treatment:
15mg PO BID x3 weeks, then 20mg daily with food
NV Atrial fibrillation:
20mg PO daily (15mg if CrCl 15-50mL/min)
Secondary prevention:
20mg PO daily for 6-12 mos, after initial 6-12 mo tx
rivaroxaban SE
Bleeding
Black box spinal/epidural hematoma and premature D/C increases risk thrombotic event
edoxaban dosing
DVT/PE treatment (after 5-10 days parenteral therapy):
60mg PO daily if CrCl >50 mL/min
30mg PO daily if CrCl 15-50 mL/min, body weight ≤60kg, or Pgp inhibitors
NV atrial fibrillation:
60mg PO daily if CrCl 50-95 mL/min
30mg PO daily if CrCl 15-50 mL/min
edoxaban SE
Bleeding
Black box spinal/epidural hematomas, premature discontinuation increases risk thrombotic event
Less efficacy in NVAF patient CrCl >95 mL/min
apixaban dosing
DVT prophylaxis:
2.5mg PO BID
DVT/PE treatment:
10mg PO BID x7 days, then 5mg BID x6 mos (2.5 after)
NV atrial fibrillation:
5mg PO BID
2.5mg PO BID if 2 of:
age at or above 80 years, weight 60kg or less, SCr 1.5mg/dL or higher
OR dialysis + age over 80 years OR weight under 60kg
apixaban SE
Bleeding
Black box spinal/epidural hematomas, premature discontinuation increases risk thrombotic event
lepirdin dosing
HIT:
0.15 mg/kg/h (± 0.4 mg/kg bolus)
lepirudin SE
bleeding
lepirdun monitoring
Goal aPTT 1.5-2.5
Reduce dose if CrCl less than 60mL/min
bivalirudin dosing
HIT or UFH alternative during PCI:
0.7 mg/kg bolus + 1.75 mg/kg/h infusion
bivalirudin SE
bleeding
argatroban dosing
HIT:
2 mcg/kg/min
0.5 mcg/kg/min if hepatic insufficiency
argatroban SE
bleeding
argatroban monitoring
Elevates INR falsely; overlap with warfarin until INR ≥4
dabigatran dosing
DVT/PE treatment after 5-10 days parenteral anticoag: 150mg PO BID for CrCl ≥30 mL/min NV atrial fibrillation: 150mg PO BID if CrCl >30 mL/min 75mg PO BID if 15-30 mL/min
dabigatran SE
Dyspepsia
Bleeding
Keep in manufacturer bottle
dabigatran monitoring
do not use in > 75
alteplase dosing
10mg IV bolus + 90mg infusion over 2 hours
Most commonly for PE
alteplase SE
bleeding
reteplase dosing
10 units IV over 2 minutes + second dose in 30 mins
For ACS only
reteplase SE
bleeding
tenecteplase dosing
30mg + 5mg/10kg over 60kg up to 50mg as IV bolus
For ACS only
tenecteplase SE
bleeding
urokinase dosing
VTE treatment:
4400 units/kg bolus over 10 minutes
+ 4400 units/kg/hour for 12 hours
urokinase SE
bleeding
warfarin SE
bleeding
pregnancy X
warfarin monitoring
CYP2C9, 3A4, 2C19, 1A2 interactions
Goal INR 2.0 – 3.0
*mechanical mitral/caged ball/high risk artificial valve
goal INR 2.5 - 3.5
