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Pharmacotherapy II > VTE Lab Formulary > Flashcards

VTE Lab Formulary Flashcards

1
Q

Enoxaparin brand name

A

Lovenox

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2
Q

What is the prophylactic dose of enoxaparin?

A

30mg SQ BID
40mg SQ daily
If CrCl less than 30mL/min:
30mg SQ daily

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3
Q

What is the treatment dose of enoxaparin?

A

1mg/kg SQ BID
1.5mg/kg SQ daily
If CrCl less than 30mL/min:
1mg/kg SQ daily

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4
Q

What is the anti-Xa goal in patients on BID enoxaparin? Daily enoxaparin?

A

BID: 0.6-1u/mL peak
QD: 0.1-0.3u/mL trough (or 1-2u/mL peak)

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5
Q

Dalteparin brand name

A

Fragmin

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6
Q

What is the prophylactic dose of dalteparin?

A

2500-5000 IU SQ daily

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7
Q

What is the treatment dose of dalteparin?

A

200 IU/kg SQ daily (MAX 18000 IU)

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8
Q

What is the anti-Xa goal in patients with CrCl

A

0.5-1.5 u/mL

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9
Q

Tinzaparin brand name

A

Innohep

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10
Q

What is the treatment dose of tinzaparin?

A

175 anti-Xa IU/kg SQ daily

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11
Q

Fondaparinux brand name

A

Arixtra

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12
Q

What is the prophylactic dose of fondaparinux?

A

2.5mg SQ daily (not for patients less than 50kg or CrCl less than 30mL/min)

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13
Q

What are the treatment doses of fondaparinux (broken up by weight)?

A

Less than 50kg: 5mg SQ daily
50-100kg: 7.5mg SQ daily
Over 100kg: 10mg SQ daily

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14
Q

What are the two possible routes of unfractionated heparin administration?

A

IV or SQ (not IM)

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15
Q

What lab is monitored for UFH therapy?

A

aPTT (therapeutic range 1.5-2.5x normal)

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16
Q

How often is aPTT monitored in UFH therapy?

A

At baseline, 6 hours after dose or dose change, daily after 1st day.

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17
Q

How is UFH dosed using a weight based approach?

A

80 units/kg IV bolus + 18 units/kg/hr infusion

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18
Q

How is UFH dosed subcutaneously prophylactically?

A

5000 unit IV bolus + 1000-1200 units/hour

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19
Q

How is UFH dosed subcutaneously for treatment?

A

17500 units SQ BID

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20
Q

Rivaroxaban brand name

A

Xarelto

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21
Q

How is rivaroxaban dosed for DVT prophylaxis?

A

10mg PO daily for 35 days in THA, 12 days in TKA

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22
Q

How is rivaroxaban dosed for DVT/PE treatment?

A

15mg PO BID x 3 weeks then 20mg PO daily with food

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23
Q

How is rivaroxaban dosed for NV atrial fibrillation?

A

20mg PO daily (15mg if CrCl 15-50mL/min)

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24
Q

How is rivaroxaban dosed for secondary prevention of VTE after initial appropriate 6 month therapy?

A

20mg PO daily for 6-12 mos

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25
Q

Edoxaban brand name

A

Savaysa

26
Q

How is edoxaban dosed for DVT/PE treatment after 5-10 days of parenteral therapy?

A

CrCl 50mL/min or greater: 60mg PO daily

CrCl 15-50mL/min, weight

27
Q

How is edoxaban dosed for NV atrial fibrillation?

A

CrCl 50-95 mL/min: 60mg PO daily

CrCl 15-50mL/min: 30mg PO daily

28
Q

Apixaban brand name

A

Eliquis

29
Q

How is apixaban dosed for DVT prophylaxis?

A

2.5mg PO BID

30
Q

How is apixaban dosed for DVT/PE treatment?

A

10mg PO BID x7 days, then 5mg BID x6 mos (2.5 after)

31
Q

How is apixaban dosed for NV atrial fibrillation?

A

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

32
Q

Dabigatran brand name

A

Pradaxa

33
Q

How is dabigatran dosed for DVT/PE treatment after 5-10 days of parenteral anticoagulation?

A

150mg PO BID for CrCl >30mL/min

34
Q

How is dabigatran dosed for NV atrial fibrillation?

A

CrCl >30mL/min: 150mg PO BID

CrCl 15-30mL/min: 75mg PO BID

35
Q

What is one patient counseling point for dabigatran?

A

Keep in manufacturer bottle and not in humid places

36
Q

How is lepirudin dosed?

A

0.15mg/kg/h (with or without 0.4mg/kg bolus)

Reduce if CrCl

37
Q

What is the target aPTT with lepirudin?

A

1.5-2.5 normal

38
Q

Bivalrudin brand name

A

Angiomax

39
Q

How is bivalrudin dosed?

A

0.7mg/kg IV bolus + 1.75 mg/kg/h infusion

40
Q

How is argatroban dosed?

A

2mcg/kg/min or 0.5mcg/kg/min if hepatic insufficiency

41
Q

What is an important clinical pearl for argatroban?

A

Falsely elevates INR–overlap with warfarin until INR >4

42
Q

tPA (alteplase) brand name

A

Activase

43
Q

How is alteplase dosed?

A

10mg IV bolus + 90mg IV infusion over 2 hours

44
Q

Reteplase brand name

A

Retevase

45
Q

How was reteplase dosed?

A

10 units IV over 2 minutes + second 10 unit dose in 30 minutes

46
Q

Tenecteplase brand name

A

TNKase

47
Q

How is tenecteplase dosed?

A

IV bolus of 30mg + 5mg/10kg over 60kg. MAX 50mg.

48
Q

Brand name for urokinase

A

Abbokinase

49
Q

How is urokinase dosed?

A

4400 units/kg bolus over 10 minutes + 4400 units/kg/hour for 12 hours

50
Q

Warfarin brand names

A

Coumadin, Jantoven

51
Q

What is an appropriate starting dose for warfarin if no other factors are known?

A

5mg PO daily

52
Q

What is the goal INR on warfarin therapy?

A
  1. 0 - 3.0

* except for mechanical mitral/caged ball/high risk valve–2.5-3.5*

53
Q

What is an appropriate action if a patient’s INR is 3.2 on warfarin?

A

Decrease weekly dose by 5-15% if no clear cause

54
Q

What is an appropriate action if a patient’s INR is 3.7 on warfarin?

A

Hold 0-1 dose and decrease weekly dose by 10-15% if no clear cause

55
Q

What is an appropriate action if a patient’s INR is 1.5 on warfarin?

A

Increase weekly dose by 5-15%

56
Q

What is an appropriate action if a patient’s INR is 4.1 on warfarin?

A

Hold 0-2 doses and decrease weekly dose by 10-15% if no clear cause

57
Q

What is a major genetic source of warfarin pharmacokinetic variability?

A

Variation in CYP2C9 expression

58
Q

How soon should an INR be checked if a patient’s dose was held today?

A

In 1-2 days

59
Q

How soon should an INR be checked if a patient’s warfarin dose was changed today?

A

Within 1-2 weeks

60
Q

What is the longest you can go without checking an INR in a patient stable on one warfarin dose for 6 months?

A

Every 12 weeks

Pharmacotherapy II (15 decks)

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