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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
Challenges of Warfarin
-narrow therapeutic window -subject variability -interactions -labs hard to standardize -good PK/PD understanding by bot patient/provider
26
Warfarin MOA
-inhibits enzymes that convert vit K -inhibits Factors II, VII, IX, X -inhibits protein C and S -doesnt effect already formed thrombi
27
Warfarin PK
-effect within 24h -peak 72-96h -2-5 day duration -CYp450 metabolism in liver
28
half/life of vit K factors
-prothrombin (II): 60-100h -VII: 4-6h -IX and X: 20-40
29
Warfarin genetic variances
-CYP2C9 -VKORC1
30
CYP2C9 and warfarin
-dec Cl 40-90% -lower dose requirement -some more common in asians and AA -inc bleeding risk and longer time to goal
31
VKORC1 and warfarin
-dec production -inc sensitivity (A lower the dose avg to 3mg) -inc resistance (inc dose avg 6mg) -mostly white and asian
32
Who to test
-if available before 6th dose and patient is at high risk of bleeding if INR increases
33
Warfarin-drug interactions that increase INR
-Mteronidazole -Amiodarone -Fluconazole -Ciprofloxacin -Bactrim -alcohol -liver disease
34
Warfarin drug interactions that decrease INR
-Rifampin -also alcohol
35
Aspirin and NSAID
-inc bleeding risk but not INR
36
Food interactions w Warfarin
-activity reversed by vitamin K -need to pt educate
37
Acute alc use and warfarin
-inc warfarin effect by inhibiting metabolism
38
Chronic alcohol use and warfarin
-enhances metabolism by inducing hepatic enzymes =DEC effect of warfarin
39
Chronic alcohol use w liver damage and warfarin
-inc effect bc no hepatic enzymes =lower dose
40
Antiplatelet drugs
-Aspirin (COX) -ADP inhibitors -GPIIB/IIIa blockers -P3 inhibitors (dipyridamole) -protease-activated receptor inhibitors
41
Antiplatelet use in VTE
-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
Bleeding management
-d/c med -apply compression -maintain BP -surgery -blood products +/- PCC +/- targeted antidotes -consider activated charcoal < 2h bleeding -hemodialysis dabigatran only -tranexamic acid
43
Targeted reversal of bleeding
-UFH, LMWH: protamine sulfate -Dabigatran: idaruxizumab -factor Xa inhibitors: andexanet
44
Protamine sulfate
-UFH and LMWH antidote
45
Protamine for UFH infusion
-1mg protamine per every 100 units UFH given over past 3 hours
46
Protamine for LMWH
-within 8 hours: 1mg/100 anti-Xa units and 1mg/1mg enoxaparin -after 8 hours: 0.5/100 and 0.5/1
47
Protamine sulfate adverse reactions
-HYPOtension -bradycardia -slow infusion over 1-3 minutes -max 50mg over 10 minutes
48
Idarucizumab
-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
Idarucizumab side effects
-delirium -HA -hypokalemia -constipation -pneumonia -fever
50
Andexanet alfa
-binds and sequesters FXa inhibitors (rivaroxaban and apixaban) -no monitoring
51
Andexanet alfa dosing
-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
Low dose andexanet alfa
-400mg IV bolus at 30mg/min then 4mg/min IV infusion for up to 120min after 2 min
53
High dose andexanet alfa
-800mg IV bolus at 30mg/min then 8mg/min IV infusion for up to 120min after 2 min
54
Andexanet alfa side effects
-site reaction -DVT -stroke -AMI -PE -UTI -pneumonia
55
Warfarin bleeding management
-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
Warfarin bleeding management w INR 4.5-10 and no bleeding
-avoid vit k
57
Warfarin bleeding management w INR >10 and no bleeding
-PO vit K 5mg
58
Major bleeding while on warfarin
-PCC preferred of FFP -may add vit k 5-10mg too
59
Warfarin rapid reversal
-15 min -Prothrombin complex concentrate (PCC) + IV vit K
60
Fast warfarin reversal
-Fresh frozen plasma -10-15ml/kg
61
Prompt warfarin reversal (4-6h)
-IV vit K -do not exceed 1mg/min
62
slow warfarin reversal (24h)
-PO vit K
63
Very slow warfarin reversal (3-5 days)
-d/c warfarin
64
VTE prophylaxis
-UFH -LMWH -Factor Xa inhibitors -Vit K antagonists
65
Low VTE risk
-minor surgery -full ambulatory med pt -NO tx needed -early and aggressive ambulation
66
Moderate VTE risk
-gen surgery pt -tx w UFH, LMWH, Factor Xa inhibitor (fondaparinux) -continue prophylaxis 28 days after hospiral discharge
67
Moderate VTE risk in acutely ill medical pt
-UFH, LMWH, fondaparinux, rivaroxaban (31-39days total), betrixaban (35-42)
68
High VTE risk
-orthopedic surgery -LMWH -fonaparinux -rivaroxaban -dabigatran (hip) -UFH -vit K antagonist -continue 10-14 days post op consider 35 days
69
High bleeding risk
-mechanical prophylaxis preferred -intermittent compression devices -foot pumps -compression stockings
70
slide 61
slide 62
71
CHA2DS2-VASc score
-risk factors for stroke of systemic VTE -PO anticoagulation if over 2
72
HAS-BLED score
-risk factors for bleeding -
73
Atrial fibrilation
-afib inc risk of stroke or systemic VTE 5fold -anticoagulant therapy reduces risk
74

Therapeutics II (55 decks)

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