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Therapeutics II > VTE pre > Flashcards

VTE pre Flashcards

1
Q

Unfractionated heparin (UFH)

A

-rapid, parenteral
-anticoagulant
-variable dose response
-weight-based dosing

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2
Q

Variable dose response of UFH

A

=need for aPTT monitoring
-aPPT = activated Partial Thromboplastic Time
-goal: 1.5-2.5 time control

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3
Q

Unfractionated heparin weight-based dosing

A

-initial: 80 units/kg IV bolus then 18 units/kg/hr infusion
-APTT < 35s (<1.2): 80/+4
–APTT 35-45s (1.2-1.4): 40/+2
-APTT 46-70s (1.5-2.5): no change
-APTT 71-90s (2.6-3): dec infusion rate by 2

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4
Q

Weight-based dosing of UFH monitoring

A

-aPTT at baseline
-6h after dose or with each dosage for first 24h
-check daily after first day

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5
Q

Heparin Associated Thrombocytopenia (HAT)

A

-HIT-type I
-non-immune mediated
-mild dec in platelets
-49-72 hours after admin of heparin
-transient
-do not need to d/c heparin

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6
Q

Heparin Induced Thrombocytopenia (HIT)

A

-immune mediated
-thrombotic complications
-7-14 days after taking heparin
-can occur up to 9 days after d/c
-platelets drop > 50% from baseline

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7
Q

HIT management

A

-stop all heparin
-give alt anticoagulant
-do not give platelet infusion
-do not give warfarin platelet count > 150k
-evaluate for thrombosis

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8
Q

Low molecular weight heparin

A

-better than UFH
-good availability
-predictable dose response
-no resistance
-fixed or weight-based dosing
-no need to monitor
-longer half-life qd or BID
-improved absorption bc smaller
-reduced risk of HIT and maybe bleeding

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9
Q

Low molecular weight heparin drugs

A

-enoxaparin
-dalteparin

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10
Q

Enoxaparin dosing prophylaxis

A

-30mg SQ q 12h (surgery)
-40mg SQ qd (medical

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11
Q

Enoxaparin dosing for treatment

A

-1mg/kg SQ q12
-1.5mg/kg SQ qd

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12
Q

Enoxaparin dosing for renal dysfunction

A

-30mg SQ qd
-1mg/kg SQ qd

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13
Q

Dalteparin dosing for prophylaxis

A

-2500-5000 units SQ qd
-200 units/kg SQ qd 30 days then 150 units SQ qd (cancer)

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14
Q

Monitoring parametersLMWH

A

-anti-Xa levels
-consider in kids, kidney failure, obesity, long course, pregnancy

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15
Q

Anti-Xa tx

A

-BID 0.6-1 units/ml 4h post dose
-dq: 0.1-0.3 units/mL obtained as trough
-can consider peak 1-2 units/mL obtained 4h post dose

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16
Q

Fondaparinux

A

-injectable Xa inhibitor (FXa)
-prophylaxis follwoing THA, TKA, hip replacement, ab surgery
-tx of DVT or PE

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17
Q

Fonaparinux dosing prophylaxis

A

-2.5mg SQ qd (hip, knee, ab surgery)

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18
Q

Fonaparinux dosing for DVT or PE tx

A

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

-SQ qd

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19
Q

Fondaparinux considerations

A

-dont use in renal dysfunction (CrCl <30)
-do not use for prophylaxis w low body weight
-can use in HIT
-no monitoring
-pregnancy category B

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20
Q

IV direct thrombin inhibitors

A

-Lepirudin
-Bivalirudin
-Argatroban

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21
Q

Lepirudin

A

-IV direct thrombin inhibitor
-tx HIT
-0.15mg/kg/h +/1 0.4mg/kg bolus
-reduce dose if CrCl <60ml

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22
Q

Bivalirudin (angiomax)

A

-IV direct thrombin inhibitor
-0.7mg/kg then 1.75 mg/kg/h
-tx HIT, UFH alt during PCl

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23
Q

Argatroban

A

-2mcg/kg/min
-tx HIT
-elevates INR, overlap w warfarin unitl INR >4
-cautionhepatic dysfunctoin (0.5mcg)

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24
Q

Warfarin

A

-1-6mg
-2.5, 7.5, 10mg
-PO
-all tablets same color

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25
Q

Challenges of Warfarin

A

-narrow therapeutic window
-subject variability
-interactions
-labs hard to standardize
-good PK/PD understanding by bot patient/provider

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26
Q

Warfarin MOA

A

-inhibits enzymes that convert vit K
-inhibits Factors II, VII, IX, X
-inhibits protein C and S
-doesnt effect already formed thrombi

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27
Q

Warfarin PK

A

-effect within 24h
-peak 72-96h
-2-5 day duration
-CYp450 metabolism in liver

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28
Q

half/life of vit K factors

A

-prothrombin (II): 60-100h
-VII: 4-6h
-IX and X: 20-40

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29
Q

Warfarin genetic variances

A

-CYP2C9
-VKORC1

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30
Q

CYP2C9 and warfarin

A

-dec Cl 40-90%
-lower dose requirement
-some more common in asians and AA
-inc bleeding risk and longer time to goal

31
Q

VKORC1 and warfarin

A

-dec production
-inc sensitivity (A lower the dose avg to 3mg)
-inc resistance (inc dose avg 6mg)
-mostly white and asian

32
Q

Who to test

A

-if available before 6th dose and patient is at high risk of bleeding if INR increases

33
Q

Warfarin-drug interactions that increase INR

A

-Mteronidazole
-Amiodarone
-Fluconazole
-Ciprofloxacin
-Bactrim
-alcohol
-liver disease

34
Q

Warfarin drug interactions that decrease INR

A

-Rifampin
-also alcohol

35
Q

Aspirin and NSAID

A

-inc bleeding risk but not INR

36
Q

Food interactions w Warfarin

A

-activity reversed by vitamin K
-need to pt educate

37
Q

Acute alc use and warfarin

A

-inc warfarin effect by inhibiting metabolism

38
Q

Chronic alcohol use and warfarin

A

-enhances metabolism by inducing hepatic enzymes
=DEC effect of warfarin

39
Q

Chronic alcohol use w liver damage and warfarin

A

-inc effect bc no hepatic enzymes
=lower dose

40
Q

Antiplatelet drugs

A

-Aspirin (COX)
-ADP inhibitors
-GPIIB/IIIa blockers
-P3 inhibitors (dipyridamole)
-protease-activated receptor inhibitors

41
Q

Antiplatelet use in VTE

A

-limited use
-ASA for CHADSVASC score 1
-dipryidamole w warfarin for prostetic heart valves
-adj role to thrombolytics
-significant role in ACS and other arterial ischemic vascular disorders

42
Q

Bleeding management

A

-d/c med
-apply compression
-maintain BP
-surgery
-blood products +/- PCC +/- targeted antidotes

-consider activated charcoal < 2h bleeding
-hemodialysis dabigatran only
-tranexamic acid

43
Q

Targeted reversal of bleeding

A

-UFH, LMWH: protamine sulfate
-Dabigatran: idaruxizumab
-factor Xa inhibitors: andexanet

44
Q

Protamine sulfate

A

-UFH and LMWH antidote

45
Q

Protamine for UFH infusion

A

-1mg protamine per every 100 units UFH given over past 3 hours

46
Q

Protamine for LMWH

A

-within 8 hours: 1mg/100 anti-Xa units and 1mg/1mg enoxaparin
-after 8 hours: 0.5/100 and 0.5/1

47
Q

Protamine sulfate adverse reactions

A

-HYPOtension
-bradycardia
-slow infusion over 1-3 minutes
-max 50mg over 10 minutes

48
Q

Idarucizumab

A

-direct binder to dabigatran (higher affinity than thrombin)
-2 2.5g doses less than 15 min apart (5g IV)
-monitor aPTT repeat in 2 hours then q12h til normal

49
Q

Idarucizumab side effects

A

-delirium
-HA
-hypokalemia
-constipation
-pneumonia
-fever

50
Q

Andexanet alfa

A

-binds and sequesters FXa inhibitors (rivaroxaban and apixaban)
-no monitoring

51
Q

Andexanet alfa dosing

A

-low dose if less than or equal to 5mg apixaban or 10mg rivaroxaban
-high dose if over
-if more than 8h then use low dose

52
Q

Low dose andexanet alfa

A

-400mg IV bolus at 30mg/min then 4mg/min IV infusion for up to 120min after 2 min

53
Q

High dose andexanet alfa

A

-800mg IV bolus at 30mg/min then 8mg/min IV infusion for up to 120min after 2 min

54
Q

Andexanet alfa side effects

A

-site reaction
-DVT
-stroke
-AMI
-PE
-UTI
-pneumonia

55
Q

Warfarin bleeding management

A

-depends on INR and presence/absence bleeding
-Vit K (5mg PO)(anaphylaxis over 1mg/min IV)
-fresh frozen plasma (10-15ml/kg)
-Prothrombin Complex concentrate (30IU/kg) check INR before and 30-60 min

56
Q

Warfarin bleeding management w INR 4.5-10 and no bleeding

A

-avoid vit k

57
Q

Warfarin bleeding management w INR >10 and no bleeding

A

-PO vit K 5mg

58
Q

Major bleeding while on warfarin

A

-PCC preferred of FFP
-may add vit k 5-10mg too

59
Q

Warfarin rapid reversal

A

-15 min
-Prothrombin complex concentrate (PCC) + IV vit K

60
Q

Fast warfarin reversal

A

-Fresh frozen plasma
-10-15ml/kg

61
Q

Prompt warfarin reversal (4-6h)

A

-IV vit K
-do not exceed 1mg/min

62
Q

slow warfarin reversal (24h)

A

-PO vit K

63
Q

Very slow warfarin reversal (3-5 days)

A

-d/c warfarin

64
Q

VTE prophylaxis

A

-UFH
-LMWH
-Factor Xa inhibitors
-Vit K antagonists

65
Q

Low VTE risk

A

-minor surgery
-full ambulatory med pt
-NO tx needed
-early and aggressive ambulation

66
Q

Moderate VTE risk

A

-gen surgery pt
-tx w UFH, LMWH, Factor Xa inhibitor (fondaparinux)
-continue prophylaxis 28 days after hospiral discharge

67
Q

Moderate VTE risk in acutely ill medical pt

A

-UFH, LMWH, fondaparinux, rivaroxaban (31-39days total), betrixaban (35-42)

68
Q

High VTE risk

A

-orthopedic surgery
-LMWH
-fonaparinux
-rivaroxaban
-dabigatran (hip)
-UFH
-vit K antagonist
-continue 10-14 days post op consider 35 days

69
Q

High bleeding risk

A

-mechanical prophylaxis preferred
-intermittent compression devices
-foot pumps
-compression stockings

70
Q

slide 61

A

slide 62

71
Q

CHA2DS2-VASc score

A

-risk factors for stroke of systemic VTE
-PO anticoagulation if over 2

72
Q

HAS-BLED score

A
73
Q

Atrial fibrilation

A

-afib inc risk of stroke or systemic VTE 5fold
-anticoagulant therapy reduces risk

74
Q
A

Therapeutics II (38 decks)

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