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662 > VTE Prophylaxis > Flashcards

VTE Prophylaxis Flashcards

1
Q

Prophylaxis goal?

A

Identify patient risk Determine risk level Select the correct regimen pharm and non pharm

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2
Q

Non pharm treatment Therapy for VTE

A

Graduated compression stockings (GCS) - good for low or moderate risk Can wear leg too big - IPC- intermittent pneumatic compression increase circulation

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3
Q

Pharmacologic Prophylaxis

A

Duration is unclear but once patient can ambulate or other RFs are gone then dc therapy - Knee replacement, treatment for 12 days after - Hip replacement 35 days after

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4
Q

Standard dosing for LMWH ?

A

Regardless of weight

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5
Q

Risk Level

A
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6
Q
  • What are the goals for VTE treatment?
A
  • Prevent short term complications within 6 months
      • Prevent extension of clot
        • Prevent embolism clot
        • Prevent death
    • Prevent long term complications past 6 months
      • Post thrombotic syndrome
      • Pulmonary HTN
      • Recurrent VTE
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7
Q

UFH is from?

Does what to clots?

A

From procine stomach or bovine lung

Does not dissove clot but prevents growth

Binds to AT

neutralizes Thrombin factors Xa IX, Xia, XIIa

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8
Q

UFH is administered?

Non specific binding site so?

A

IV and Sub Q

Sub Q onset is 1-2 hours

Poor bioavailability

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9
Q

It is critical to achieve ___ of UFH within the first?

What type of dosing is there?

A

therapeutic dose within 24 hours

Weight base

Standard dose

VTE chart

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10
Q

UFH requires close monitoring and is done by the lab test?

A

Activated partial thromboplastin time (aPTT)

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11
Q

Normal therapeutic range for aPTT?

___ to ___ the control aPTT value

A

28-42 seconds

1.5 to 2.5

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12
Q

Baseline aPTT is done?

A

6 hours after starting UFH infusion and 6 hours have dose change

Takes 6 hours to reach steady state

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13
Q

Adverse effects of UFH/

A
  • Bleeding
  • Thrombocytopenia
    • HIT in 5%
  • Long term use can casue Alopecia, Hyperkalemia, Osteoporosis
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14
Q

HIT

A
  • Is an immune system clotting disorder
    • Formation of abnormal antibodies cause platelet activation
  • Monitor platelets every 2-3 days during UFH therapy
  • If platelets fall below 50% from baseline or below 120000 think HIT
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15
Q

UFH antidote?

A

Protamine

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16
Q

UFH is ok to using in ___ patients

if patient is ____

Contraindication?

A

Pregnant

Can breastfeed

Contraindication is Hx of HIT

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17
Q

LMWH

A

Binds to Xa not much to do with thrombin

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18
Q

Advantages of LMWH?

A
  • The anticoagulant response is more predictable less binding to plasma and cellular proteins
    • Reduced need for monitoring
  • Improved SUB Q bioavailability
  • Longer half life
  • Lower chance of HIT
  • Lower chance of osteoporosis
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19
Q

LMWH products

Parin, Parin, Parain

A

Dalteparin

Enoxaparin

Tinzaparain

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20
Q

LMWH has much greater effect on ___

but a draw back is that there is no?

A

Xa activity

has no antidote

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21
Q

Priot to therapy of LMWH you should?

Dosing is strictly ____ based

Given ___ in ___

A

Baseline PT/INR, aPTT, CBC w/ platelet, serum creatinine

Weight based

QD or BID

Given Sub Q in the abdomen

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22
Q

AE of LMWH?

Contraindications?

A
  • Bleeding
  • Bruising
  • HIT lower risk though
  • Contraindicated if Hx of HIT or suspected HIT
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23
Q

Protamine can be used as an antidote for LMWH but it only neutralizes it by?

A

60%

24
Q

LMWH is a great choice over UFH in patients that are?

A

pregnant

25
Q

If it is an uncomplicated DVT most patients can treat from?

But the regimen must be?

This reduces?

A

From home

Strict regimen

Cost saving

26
Q

Factor Xa inhibitors?

A
  • Fandaparinux SUB Q
  • Rivaroxaban
  • Apixaban
  • Edoxaban
27
Q

Fondaparinux is indicated for?

A
  • Prophylaxis of DVT in patients undergoing surgery
  • Treatment of DVT or PE when administered with warfarin
28
Q

Fondaparunix has a ___ onset

___ elminated no ___ metabolism

Long ___

A

rapid onset

renally eliminated no liver metabolism

long half life

29
Q

AE of Fondaparinux?

If major bleeding?

Life threatening bleeding

A
  • Bleeding, monitor CBC at baseline
  • If major bleeding then
    • Fresh frozen plasma
    • Factor concentrates
  • Life threatening bleed
    • Factor VIIa super expensive
30
Q

Rivaroxaban and Apixaban

Substrates of?

A

CYP3A4 and p-glycoprotein

Drugs that inhibit this increase levels significantly (Ketoconazole, ritonavir, clarithromycin)

Drugs that induce these may decrease levels (Carbamazepine, phenytoin, amiodarone, macrolides, diltiazem, rifampin, St johns)

31
Q

Currently there is no ___ for Rivoraxaban and Apixaban

It is also very ___

A

Antidote

costly compared to warfarin

32
Q

Edoxaban

Indicated for?

Cost compared to rivoroxaban?

Avoid what?

A

Treatment of DVT an PE

rifampin

Costs less than Rivo and APixa

33
Q

Direct Thrombin Inhibitors?

What do they do?

A
  • Bind directly to Thrombin and prevent
    • Formation of fibrin
    • positive feedback mechanism of thrombin
    • Platelet activation
    • Factor V, VIII, XI, XIII activation
  • Anticoag independent of AT
    • Able to inhibit circulation of clot bound thrombin
34
Q

DTI drugs?

A

Rudin- SC injection and not indicated for HIT

Argatroban- IV

Dabigatran- PO

35
Q

Advantages of using a DTI?

A
  • Specific for thrombin
  • Inactivate clot bounf thrombin
  • No interaction with platelet factor 4 (PF4)
  • Have not been assoiciated with osteoporosis
36
Q

Desirudin is indicated for?

A
  • Prevention of DVT in elective hip surgery
  • SC admin
  • Dose every 12 hours
  • Renally eliminated
  • Monitor with aPTT
37
Q

Argatroban?

Admin?

Binds to?

Metabolized?

No effect if?

Monitor with?

Approved for the treatment of?

A
  • Binds to thrombin
  • IV
  • Liver metabolism
  • No effect if renally impaired
  • Monitor with aPTT

Approved in the treatment of HIT

38
Q

Dabigatran?

Treatmetn of?

Admin?

Metabolized?

Avoid use with?

Avoid p-gp inhibitors if CrCL

A
  • Treatment of DVT and PE
  • Prevention of DVT and PE in hip replacement therapy
  • Metabolized by liver excreted by kindeys
    • Avoid if CrCL < 30 mL/min
  • Avoid use with P-gp inducers
  • 50 mL/min
39
Q

Dabigatran antidote?

A

Idarucizumab

IV infusion or bolus

40
Q

DTIs AE

If major bleeding give?

A
  • Bleeding is the most common side effect
  • No antidate expect for Dabigatran
  • Major bleeding give
    • FFP
    • Factor concetrates
      • Prothrombin complex concentrates
    • Recombinant factor VIIa
41
Q

Warfarin is the ___ anticoagulant

Indicated for?

A

Oral anticoagulant

Prevention and treatment of VTE

42
Q

Warfarin is a very effective drug but?

A
  • Has a narrow therapeutic window
  • Frequent dose admin
  • Patient monitoring
  • DIs
  • Food interactions
43
Q

Warfarin

____ if clotting factor already formed

___ anticoag delayed __ to ___ days

Potential for _________ state

A

No effect

Full 7 to 15 days

hypercoagulable state

44
Q

Warfarin is highly

Hepatically metabolized by?

A

Highly protein bound (albumin)

Metabolized by CYP450 1A2, 2C9, 3A4

45
Q

Warfarin does not follow linear kinetics

Individual dose determined by?

A
  • Patients response
  • Intensity of anticoagulation needed
  • Diet
  • D-D interactions
  • health

Lots of monitoring

46
Q

Warfarin

If pt is < 55 and healthy

Start at ___ mg daily ot less if patient is?

A

7.5 - 10

  • >75
  • CHF
  • Liver failure
  • Poor nutrition
  • Taking interacting meds
  • high risk of bleeding
47
Q

International Normalized Ration or INR is?

A
  • Standard practice for monitoring
  • INR range 2 -3 for treatmetn and prevention of VTE (target is 2.5)
48
Q

When starting warfarin INR should be monitored every for the 1st week?

Less frequent if?

Ask pt about?

A

2-3 days

  • Weekly for 1-2 weeks
  • monthly 4 weeks
  • If stable INR test q 12 weeks

Ask pt about adherence, vit K food, EtOH, Health

49
Q

Warfarin if VTE then ____ overlapped with warfarin?

A

rapid acting anticoagulant

minimum of 5 days

And stable INR >= 2

Adjust dose based on total weekly dose

If dose is adjusted then wait and recheck INR

50
Q

Major adverse effect of warfarin is?

what else

High INR = ?

Instability and large fluctuations in INR?

A

Bleeding

DI bleeding ICH

Intensity of anticoagulant related to bleeding

higher bleeding risk

bleeding risk

51
Q

Warfarin overdose can be corrected with?

A

Vit K

if not working use FFP and Clotting factor concentrates

52
Q

INR 4.5 - 10

INR > 10

A

Hold 1-2 warfarin doses and decrease dose

Hold 1-2 doses and resume at lower dose

53
Q

Vit K Foods?

A

Anything green, chick peas, tea

54
Q

Patient education of warfarin?

A
  • Compliance is key
  • SE
  • Dietary instructions
  • Frequent INR monitoring
  • Physical activity
  • No prego
  • Take at night
55
Q

Recommened Duration of Long term anticoagulation

A
56
Q

Risk factors for bleeding while taking Anti coags

A
57
Q
A

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