VTE Lab Formulary Flashcards
Enoxaparin brand name
Lovenox
What is the prophylactic dose of enoxaparin?
30mg SQ BID
40mg SQ daily
If CrCl less than 30mL/min:
30mg SQ daily
What is the treatment dose of enoxaparin?
1mg/kg SQ BID
1.5mg/kg SQ daily
If CrCl less than 30mL/min:
1mg/kg SQ daily
What is the anti-Xa goal in patients on BID enoxaparin? Daily enoxaparin?
BID: 0.6-1u/mL peak
QD: 0.1-0.3u/mL trough (or 1-2u/mL peak)
Dalteparin brand name
Fragmin
What is the prophylactic dose of dalteparin?
2500-5000 IU SQ daily
What is the treatment dose of dalteparin?
200 IU/kg SQ daily (MAX 18000 IU)
What is the anti-Xa goal in patients with CrCl
0.5-1.5 u/mL
Tinzaparin brand name
Innohep
What is the treatment dose of tinzaparin?
175 anti-Xa IU/kg SQ daily
Fondaparinux brand name
Arixtra
What is the prophylactic dose of fondaparinux?
2.5mg SQ daily (not for patients less than 50kg or CrCl less than 30mL/min)
What are the treatment doses of fondaparinux (broken up by weight)?
Less than 50kg: 5mg SQ daily
50-100kg: 7.5mg SQ daily
Over 100kg: 10mg SQ daily
What are the two possible routes of unfractionated heparin administration?
IV or SQ (not IM)
What lab is monitored for UFH therapy?
aPTT (therapeutic range 1.5-2.5x normal)
How often is aPTT monitored in UFH therapy?
At baseline, 6 hours after dose or dose change, daily after 1st day.
How is UFH dosed using a weight based approach?
80 units/kg IV bolus + 18 units/kg/hr infusion
How is UFH dosed subcutaneously prophylactically?
5000 unit IV bolus + 1000-1200 units/hour
How is UFH dosed subcutaneously for treatment?
17500 units SQ BID
Rivaroxaban brand name
Xarelto
How is rivaroxaban dosed for DVT prophylaxis?
10mg PO daily for 35 days in THA, 12 days in TKA
How is rivaroxaban dosed for DVT/PE treatment?
15mg PO BID x 3 weeks then 20mg PO daily with food
How is rivaroxaban dosed for NV atrial fibrillation?
20mg PO daily (15mg if CrCl 15-50mL/min)
How is rivaroxaban dosed for secondary prevention of VTE after initial appropriate 6 month therapy?
20mg PO daily for 6-12 mos
Edoxaban brand name
Savaysa
How is edoxaban dosed for DVT/PE treatment after 5-10 days of parenteral therapy?
CrCl 50mL/min or greater: 60mg PO daily
CrCl 15-50mL/min, weight
How is edoxaban dosed for NV atrial fibrillation?
CrCl 50-95 mL/min: 60mg PO daily
CrCl 15-50mL/min: 30mg PO daily
Apixaban brand name
Eliquis
How is apixaban dosed for DVT prophylaxis?
2.5mg PO BID
How is apixaban dosed for DVT/PE treatment?
10mg PO BID x7 days, then 5mg BID x6 mos (2.5 after)
How is apixaban dosed for NV atrial fibrillation?
5mg PO BID unless…
2 of age >80, weight less than 60kg, or SCR 1.5mg/dL or greater
OR dialysis + age >80 or weight less than 60kg
Dabigatran brand name
Pradaxa
How is dabigatran dosed for DVT/PE treatment after 5-10 days of parenteral anticoagulation?
150mg PO BID for CrCl >30mL/min
How is dabigatran dosed for NV atrial fibrillation?
CrCl >30mL/min: 150mg PO BID
CrCl 15-30mL/min: 75mg PO BID
What is one patient counseling point for dabigatran?
Keep in manufacturer bottle and not in humid places
How is lepirudin dosed?
0.15mg/kg/h (with or without 0.4mg/kg bolus)
Reduce if CrCl
What is the target aPTT with lepirudin?
1.5-2.5 normal
Bivalrudin brand name
Angiomax
How is bivalrudin dosed?
0.7mg/kg IV bolus + 1.75 mg/kg/h infusion
How is argatroban dosed?
2mcg/kg/min or 0.5mcg/kg/min if hepatic insufficiency
What is an important clinical pearl for argatroban?
Falsely elevates INR–overlap with warfarin until INR >4
tPA (alteplase) brand name
Activase
How is alteplase dosed?
10mg IV bolus + 90mg IV infusion over 2 hours
Reteplase brand name
Retevase
How was reteplase dosed?
10 units IV over 2 minutes + second 10 unit dose in 30 minutes
Tenecteplase brand name
TNKase
How is tenecteplase dosed?
IV bolus of 30mg + 5mg/10kg over 60kg. MAX 50mg.
Brand name for urokinase
Abbokinase
How is urokinase dosed?
4400 units/kg bolus over 10 minutes + 4400 units/kg/hour for 12 hours
Warfarin brand names
Coumadin, Jantoven
What is an appropriate starting dose for warfarin if no other factors are known?
5mg PO daily
What is the goal INR on warfarin therapy?
- 0 - 3.0
* except for mechanical mitral/caged ball/high risk valve–2.5-3.5*
What is an appropriate action if a patient’s INR is 3.2 on warfarin?
Decrease weekly dose by 5-15% if no clear cause
What is an appropriate action if a patient’s INR is 3.7 on warfarin?
Hold 0-1 dose and decrease weekly dose by 10-15% if no clear cause
What is an appropriate action if a patient’s INR is 1.5 on warfarin?
Increase weekly dose by 5-15%
What is an appropriate action if a patient’s INR is 4.1 on warfarin?
Hold 0-2 doses and decrease weekly dose by 10-15% if no clear cause
What is a major genetic source of warfarin pharmacokinetic variability?
Variation in CYP2C9 expression
How soon should an INR be checked if a patient’s dose was held today?
In 1-2 days
How soon should an INR be checked if a patient’s warfarin dose was changed today?
Within 1-2 weeks
What is the longest you can go without checking an INR in a patient stable on one warfarin dose for 6 months?
Every 12 weeks
