VTE In Class Slides

Question 1

Postoperative prophylaxis

Answer 1

dabigatran (hip replacement only)
rivaroxaban (hip or knee replacement)
apixaban (hip or knee replacement)

Question 2

Non-valvular atrial fibrillation

Answer 2

irregular heart rhythm –> increased risk of stroke or systemic embolism
dabigatran
rivaroxaban
apixaban - (adjustment based on SCr no CrCl like the others) 2 of the following: age >/= 80yrs, body weight </= 60kg or serum creatinine >/= 1.5 mg/dL: 2.5 mg BID instead of 5 mg BID
edoxaban - CrCl > 95 mL/min: use is not recommended (performed worse with better renal function)

Question 3

DVT/PE treatment

Answer 3

dabigatran - requires 5-10 days parenteral anticoagulation (injectable 1st, oral option 2nd; parenteral anticoagulant - lovenox, enoxaparin)
rivaroxaban
apixaban
edoxaban - weight </= 60kg: 30 mg daily; requires 5-10 days parenteral anticoagulation

Question 4

Secondary prevention of recurrent DVT/PE

Answer 4

lower risk of clotting outweighs increased risk of bleeding
rivaroxaban - after initial 6 months of treatment
apixaban - after initial 6 months of treatment

Question 5

VTE prophylaxis

Answer 5

rivaroxaban - approved for acutely ill medical pts in the hospital

Question 6

Warfarin dosing

Answer 6

variable overtime
variable b/w pts
initial dose: 5 mg PO d (healthy outpatients: 10 mg daily for 2 days then give 5 mg)
overlap with UFH/LMWH/Xa for at least 5 days AND until INR is therapeutic (within goal 2-3)
adjust weekly dose to achieve therapeutic INR

Question 7

What is INR

Answer 7

INR is the # that represents how long it takes your blood to clot, normal INR is 1, higher it gets, higher the bleeding risk

Question 8

INR goal of 2-3 indications

Answer 8

prophylaxis of VTE
treatment of VTE or PE
prevention of systemic embolism
antiphospholipid antibody syndrome
mechanical heart valve

Question 9

INR goal of 1.5-2 indication

Answer 9

aortic valve replacement

Question 10

INR goal of 2.5-3.5 indication

Answer 10

mechanical heart valve (mitral, caged ball, high risk)

Question 11

INR monitoring

Answer 11

check at least 1 within 1st week, than check again in another week, 2 INRs within goal, check in 2 weeks

Question 12

Patient interview for those on warfarin

Answer 12

the 5 D’s
bruising/bleeding
have they taken any antibiotics since last time you saw them (interacts most with antibiotics)
ask about OTCs (Gs make you bleed)

Question 13

The 5 D’s

Answer 13

the most notable things that impact warfarin
drugs (any changes in meds)
diseases (any changes in overall medical condition and/or treatment)
doses (any missed doses)
diet (any changes in diet, specifically green leafy vegetables i.e. vit K)
drink (any EtOH consumption)

Question 14

Warfarin protocol dose alteration for INR 2-3

Answer 14

INR < 2: increase by 5-15%
INR 3.1-3.5: decrease by 5-15%
INR 3.5-4: hold 0-1 dose, decrease by 10-15%
INR > 4: hold 0-2 doses, decrease by 10-15%

Question 15

Warfarin protocol dose alteration for INR 2.5-3.5

Answer 15

INR < 2.5: decrease by 5-15%
INR 3.6-4: decrease by 5-15%
INR 4.1-4.5: hold 0-1 dose, decrease by 10-15%
INR > 4.5: hold 0-2 doses, decrease by 10-15%

Question 16

Warfarin dosing tips

Answer 16

you can adjust warfarin in half tab increments
always work with the warfarin tabs a pt already has 1st
get a pt on only 1 dose of warfarin
want to separate the higher and lower doses to minimize peaks + valleys - M, F; M, W, F; T, Th, Sat, Sun

Question 17

Invasive procedures

Answer 17

period of time anti-coagulant is stopped for a procedure
bridging therapy may be needed if on warfarin
typically not needed for dental, dermatologic, or cataract procedures
if bridging is needed: stop warfarin 5 days before surgery; give LMWH or UFH until the procedure, stop LMWH 24hrs before procedure, stop IV UFH 4-6 hours before procedure; resume warfarin 12-24 hours after surgery