Weber - AntiCoag Flashcards
which NOACs are used for post-op prophylaxis
DRA
dabigatran; Rivaroxaban; apixaban
which NOACs are used for Non-Valvular A.Fib
DRAE
dabigatran; rivaroxaban; apixaban; edoxaban
which NOACs are used for Secondary prevention of DVT/PE
RA
Rivaroxaban; Apixaban
which NOACs are used for VTE prophylaxis
Betrixaban
which NOAC for post-op prophylaxis is used for ONLY hip replacement
Dabigatran
which NOAC for post-op prophylaxis is used for hip AND knee replacement
Rivaroxaban; Apixaban
which NOACs for DVT/PE treatment are for MAINTENANCE only
Edoxaban and Dabigitran (aka need parenteral anticoag for 5 - 10 days)
which NOACs are for DVT/PE treatment for maintenance and acute?
Rivaroxaban; Apixaban
is it an inhibitor or an activator (of the coag system?)
Von Willebrand Factor
activator
is it an inhibitor or an activator (of the coag system?)
Tissue Factor
activator
is it an inhibitor or an activator (of the coag system?)
Factor VIIa
activator
is it an inhibitor or an activator (of the coag system?)
Heparin
inhibitor
is it an inhibitor or an activator (of the coag system?)
Thrombomodulin
inhbiitor
is it an inhibitor or an activator (of the coag system?)
Factor Xa
activator
is it an inhibitor or an activator (of the coag system?)
Thrombin
activator
is it an inhibitor or an activator (of the coag system?)
Tissue Plasminogen Activator
activator
is it an inhibitor or an activator (of the coag system?)
Antithrombin
inhibitor
is it an inhibitor or an activator (of the coag system?)
Protein C
inhibitor
is it an inhibitor or an activator (of the coag system?)
Protein S
inhibitor
is it an inhibitor or an activator (of the coag system?)
plasminogen activator inhibitor 1
inhibitor
which NOACs are used for DVT/PE treatment
DRAE
dabigatran; rivaroxaban; apixaban; edoxaban
what 3 things make up Virchows triad
Hypercoaguable state
Circulatory stasis
Endothelial injury
UFH:
is it specific or non specific binding
non specific
UFH: what is its MOA?
It interacts with ______ which catalyzes formation of thrombin/antithrombin complexes
it also binds to _______ and ______
ATIII; heparin; platelets
Dosing for UFH:
80 units/kg (BOLUS)
18 units/kg/hr (INFUSION)
Labeled Uses for UFH
- prophylaxis and tx of thromboembolic disorders
- Anticoag for extracorpeal (outside of body) and dialysis procedures
UFH: Pregnancy Category ______
B
aPTT stands for?
activated partial thromboplastin test
what is the therapeutic range for aPTT
1.5 - 2 times the normal
Monitoring for UFH:
@ baseline
Check @ 6 hrs (after first dose/each dose change)
Check DAILY for 1st day unless out of range)
ADEs of UFH
- bleeding
- HIT
- Osteoporsis
- hypersensitivity
HAT or HIT?
aka HIT Type 1
HAT
HAT or HIT?
Non-immune mediated
HAT
HAT or HIT?
Immune mediated
HIT
HAT or HIT?
Platelets > 100,000
HAT (that is known as mild decrease)
HAT or HIT?
Platelets decrease by more than 50%
HIT
HAT or HIT?
Platelets < 100,00
HIT
HAT or HIT?
occurs b/w 7 - 14 days
HIT
HAT or HIT?
occurs b/w 48 - 72 hours
HAT
HAT or HIT?
Need to discontinue Heparin
HIT
HAT or HIT?
Do NOT need to discontinue Heparin
HAT
how to manage HIT?
- stop all heparin products
- give alternate anticoags
- Do NOT give platelet infusions
- Do NOT give warfarin unless platelet is >150,000
- Evaluate for thrombosis
ADEs of Protamine
- Hypotension
- Bradycardia
- Anaphylaxis
Protamine Dosing
MAX 50 mg over 10 minutes
Protamine Dose per 100 units of UFH:
- immediate: 1 - 1.5
- 30 mins - 120 mins: 0.5 - 0.75
- > 120 mins: 0.25 - 0.375
LWMH: inhibits ____ more than _____
Xa; thrombin (II)
Monitoring for Enoxaparin
CBC w/ platelet
fecal occult blood
SCr
Anti-Xa levels
Max weight for enoxaparin
144 kg
Blackbox warning for LWMH:
neural anesthesia or spinal puncture can lead to increased risk of spinal hematoma leading to paralysis
what drug(s) are injectable indirect factor Xa inhibitor
Fondaparinux
what is fondaparinux’s MOA
attaches to AT(III) and prevents factor Xa from working
Fondaparinux Specifications:
Do not use if _________ or ______
(Can or Cannot) be used in HIT
Pregnancy Category ______
do not use if renal dysfunction (CrCl < 30 mL/min)
OR
do not use for prophylaxis with low body weight (<50 kg)
CAN be used in HIT
Category B
what drugs are direct IV thrombin inhibitors
Lepirudin
Bivalrudin
Argatroban
Switching DOAC from Warfarin:
Can be done when INR is what for each drug?
D: < 2
R: < 3
A: < 2
E: < 2.5
NOAC Contraindications
- recent GI bleeding
- Malignancy
- Varices (slit in esophagus)
- Arteriovenous malformations
- Recent brain/spine/eye surgery
- Concurrent use of other anticoags
Steps for bleeding management:
1 - d/c med 2 - apply manual compression 3 - maintain BP 4 - surgical or radiological intervention 5 - blood products +/- PCC
Monitoring for Idarucizumab
baseline aPTT –> repeat in 2 hours –> q12h until normal
Other Considerations that could be utilized for bleeding management:
- activated charcoal < 2 hours of bleeding
- Hemodialysis - for dabigatran ONLY
- Tranexamic Acid
Genetic Variances and Warfarin:
CYP2C9 - what are the alleles that are affected
1,2,*3
Genetic Variances and Warfarin:
CYP2C9 -
what variety occurs in 1/3 white patients
2/3
Genetic Variances and Warfarin:
CYP2C9 -
which Genetic variance needs about a 80% warfarin dose lowering
3/3
Genetic Variances and Warfarin:
CYP2C9 -
which Genetic variance needs about a 35% warfarin dose lowering
2/3 or 1/3
Genetic Variances and Warfarin:
CYP2C9 -
which Genetic variance needs about a 20% warfarin dose lowering
1/2
Genetic Variances and Warfarin:
VKORC1
what are the genetic variances for VKORC1
1639:A/G
which race is likely to have 1639AA
asian
which race is likely to have 1639GG
african americans
a 1639GG mutation leads to (decreased or increase warfarin resistance) and leads to patients needing a (lower or higher) warfarin
INcreased resistance; Higher warfarin dose
a 1639AA mutation leads to (decreased or increase warfarin sensitivity) and leads to patients needing a (lower or higher) warfarin
increased sensitivity; lower warfarin dose
what are the requirements to be genetic tested for warfarin allele mutations?
1) pt is warfarin naive
AND
2) genetic test results are available before the 6th dose
AND
3) pt is at high risk of bleeding if INR is elevated
(if ALL 3 - can do genetic warfarin testing)
How to calculate INR
(patients PT/mean normal PT)^ISI
ISI = international sensitivity index
Recommended INR Goals
For Mechanical Heart Valve (mitrial) - 2.5 - 3.5
For Everything else (2 - 3)
How to bridge UFH/LMWH/Xa to warfarin (what are the requirements)
OVERLAP for at LEAST 5 days AND wait until INR is in therapeutic range
Most patients will start at ____ mg per day
but what patients may need less than the regular starting dose
start at 5 mg;
Exceptions:
> 60 years old; debilitated; Malnourished; CHF; liver disease; Concomitant Medications; High bleeding risk; Genetic Factors
Dose Alteration for Warfarin: (Goal: 2 - 3)
if INR < 2
increase by 5 - 15%
Dose Alteration for Warfarin: (Goal: 2 - 3)
if INR 3.1 - 3.5
decrease 5 - 15%
Dose Alteration for Warfarin: (Goal: 2 - 3)
if INR 3.5 - 4.0
hold 0 - 1 doses
then decrease by 10 - 15%
Dose Alteration for Warfarin: (Goal: 2 - 3)
if INR > 4.0
hold 0 - 2 doses
decrease by 10 - 15%
