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Pharmacology > work anticoag > Flashcards

work anticoag Flashcards

1
Q

Fondaparinux (Arixtra) indications

A

VTE prophylaxis in suspected/documented HIT pt.

Therapeutic Anticoagulation in suspected/documented HIT pt.

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2
Q

Fondaparinux (Arixtra) restrictions

A

Fondaparinux (Arixtra) restrictions

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3
Q

Why use enoxaparin instead of WBH

A

Unless pt scheduled for procedure or has bleeding co-morbidities.

WBH is a high-risk drug which offers potential for errors due to need for monitoring PTT and continuous infusion. Enoxaparin has a beneficial safety profile in this pt population

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4
Q

VTE dosing notes:
Q24 hr vs q12 hr
Dose to treat DVT/PE

dose if wt 130-190 and CCE 30 ml/min

Dose if CCE 20-30 ml/min

A

We have approved the guideline through P&T and MEC that clinical staff pharmacists will automatically change dosing of 1 mg./kg q12h to 1.5 mg/kg q24h for pts that meet dosing parameters.

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5
Q

Zosyn dose for nosocomial pneumonia

A

We need to determine if it is a nosocomial pneumonia or not 1st with high suspicion of pseudomonas….if so initial dose 4.5 g q6 then renal dose from there

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6
Q

Zosyn dose for urosepsis

A

3.375 gm q6hr

then renal dose to whatever the next interval is….it is absolutely ok to give q8h if that is the corresponding interval to pts CrCl.

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7
Q

Vanco dosing considerations
Renal function
Elderly
Critically ill pt

A

As a rule, we have been using a minimum SCr of 0.8 in patients over 65 so as not to over estimate CrCl due to age-related decline in renal function. This may be causing some under dosing in our “not so old” elderly patients.

In patients over 65 with a SCr above 0.6, consider using actual SCr.·

Critically ill patients tend to have increased volume of distribution of vanco as well as increase clearance. With initial dosing, error on the “high side” ex. 750 mg IV q12h would give you a predicted trough of 16 mcg but 1 gm IV q12h predicts a trough of 21; in an acutely ill patient with stable RF, I would go with the 1 gm IV q12h, order a trough prior to the 4th dose, and adjust as necessary.·

Remember to order a Vancomycin loading dose

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8
Q

Vanco tartget trough

A

15-20 mcg/ml

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9
Q

What is the max safe Celexa dose?

Why?

A

Recent FDA Drug Safety communication warning that doses of citalopram above 40 mg/day can cause dose-dependent QT interval prolongation, which may result in abnormal heart rhythms.

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10
Q

When you Start pt on anticoag what are the dosing considerations?

A

Weight > 190 kg or

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11
Q

Dosing considerations.
Wt
renal function
platelets

A

Weight > 190 kg or

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12
Q

What is the Lovenox dose for a 450 lb pt with VTE or ACS?

A

Lovenox 1mg/kg sc q12h

max dose 190mg q12h

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13
Q

What is the Lovenox dose for VTE or ACS

A

Lovenox 1 mg/kg SC q12hr

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14
Q

Lovenox dose with decreased renal function?

A

150 mg Lovenox q24hr

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15
Q

If suspected HIT and you call the Dr what do you suggest?

A

Recommend Heparin-Antibody Test (HIT screen)·

For continuous therapeutic anticoagulation- (AF, ACS, DVT/PE) recommend a Direct Thrombin Inhibitor (Argatroban) or fondaparinux-choice based on Renal and/or Hepatic disease

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16
Q

What to do for suspected HIT?
40% platelet drop
50% platelet drop

A 
#1 Platelets - Monitoring for Heparin-Induced Thrombocytopenia (HIT)
If decrease in platelets >40%, call prescriber 
(MONITOR patients carefully)· 
#2 If it decreases platelets >50% from baseline - Call MD to D/C all enoxaparin/Heparin (including heparin-coated catheters)
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17
Q

When do you use weight based heparin?

A

CrCl

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18
Q

Lovenox dose with decreased renal function?

A

CrCl 20-29ml/min-

Decrease enoxaprin to 1mg/kg SC q24h

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19
Q

Anticoag WEIGHT less than 190kg

What is the maximum dose of Lovenox.

A

MAXIMUM dose Enoxaparin

190mg subcutaneously every 12 hours OR 190mg subcutaneously q24hrs

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20
Q

Do you need to call MD to change dose of anticoag for renal function?

A

No

You do not have to ask prescriber if you can change frequency unless they write No Substitution……………….

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21
Q

Rounding doses of Lovenox

A

All doses of enoxaparin must be rounded to the nearest 10 mg. – Do automatically send therapeutic interchange sheet

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22
Q

Lovenox Prophylaxis
Cardiac
Not cardiac
PE

A

Lovenox 1 mg/kg q12hr no sub if PE

Not cardiac 1.5 mg/kg q24hr nte 190 mg/kg

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23
Q

Lovenox Max dose

A

190 mg/kg

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24
Q

VTE prophylaxis Lovenox

A

Lovenox 30 mg or 40 mg otherwise they get heparin

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25
Q

Chest Pain Lovenox

A

Lovenox 1 mg/kg q12hr
PE change to 1.5 mg q24 hr .
Above 190 mg change to q12hr

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26
Q

Lovenox decrease renal function

A

Cut off is 30 ml/hr

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27
Q

Heparin decreased renal function, cut off

A

20 ml/hr.
No Lovenox.
Also applies to dialysis patients.

28
Q

Wt less than 45 kg

A

Heparin q12hr.

No Lovenox.

29
Q

Start therapy.
Check INR.
Do not start if INR

A

Therapeutic or > 2
If this occurs call MD and recommend not to start prophylaxis or therary.
You need an order to hold or dc

30
Q

When to discontinue therapy for DVT or PE patients?

A

You need 2 consecutive therapeutic INR to recommend discontinuation of treatment for DVT or PE.

31
Q

When to DC therapy for ACs or

A-Fib patients?

A

One therapeutic INR

32
Q

NEW anticoag Patient what 3 things to check.

A

Correct agent
correct dose
correct frequency

33
Q

Arixtra when to use

A

Only on HIT or highly suspected HIT otherwise convert to Lovenox.

Use Lovenox for orthopedic only.

34
Q

Lovenox indications

A

Ortho surgery
Spinal cord injury
Trauma

Lovenox dose 30mg Total Knee or Spinal cord injury

Lovenox dose 40 mg for total hip or hip fracture

35
Q

VTE moderate risk treatment.

A

Heparin or mechanical device if high bleeding risk.

36
Q

Heparin dose for all medical in-patient admissions.

A

Heparin 5,000 units q 8 hours

CCE

37
Q

Spinal cord injury

Total Knee

A

Lovenox 30 mg sc q12hr

38
Q

Total Hip or hip fracture

A

Lovenox 40 mg sc q12hr

39
Q

Anticoag contraindications:

A 
Active bleeding
Allergy
Uncontrolled hypertension.
Coagulopathy
HIT history
recent intraocular surgery
recent intracranial surgery
spinal tap
decrease renal function
40
Q

Heparin drip tests to monitor therapy

A

INR
CBC
platelet count
Stat PTT 6 hr after bolus or change in dose.

41
Q

Warfarin

A

Daily INR

Order a aPTT when 2 consecutive PTTs are in therapeutic range (5-104 secs)

42
Q

Lovenox indications

A 
Ortho surgery
Total Knee
Total Hip
Fx Hip
Spinal cord injury
Trauma
43
Q

Prophylaxis VTE risk factors.

A 
Surgery
Trauma (major or lower extremity injury)
Immobile, lower extremity paresis
Cancer
Cancer therapy
Venous compression- tumor hematoma, arterial abnormality
Previous VTE
Increasing age
Pregnancy and post partum period
obesity
estrogen replacement
Birth control pills
epo products
acute medical illness
nephrotic syndrome
myeloproliferative disorders
Central cath
inherited or acquired thombophilia
44
Q

Lovenox 40 mg

A

Q24 hr for Total hip

45
Q

Anticoag contraindications

A 
active bleed
allergy
uncontrolled hypertension
coagulopathy
history HIT
recent intraocular surgery 
recent intracranial surgery
spinal tap decreased renal function
decreased renal function
46
Q

CCE 20-29 ml/min anticoag to avoid

A

NO Lovenox.
IC Heparin 5,000 units sc q12hr prophylaxis.
Dialysis= NO LOVENOX

47
Q

What anticoagulant to use if patient over 190 kg?

A

NO Lovenox

Use Heparin 5,000 units sc q8hr

48
Q

Lovenox dose if BMI >50 kg/m2

A

Call MD to recommend Lovenox 40 mg q12hr.

49
Q 
Clinical Reports what to check for.
wt
cce
total hip
diagnosis
A 
Wt column for less than 45 kg
CCE less than 20 ml/min
CCE 20-29 ml/min change lovenox to Q24hr
CCE > 30 change lovenox to q12hr
Total hip dose 40 mg q24hr
Check diagnosis 
         Ortho surgery R/O DVT PE MI/ACS use treatment dose
50
Q

Platelets drops 40% what do you do?

A

Call to discuss with MD possibility of HIT.

51
Q

Platelets drops 50% what do you do?

A

Order HIT panel and call MD to stop all heparin Lovenox products.

52
Q

VTE prophylaxis

A

Lovenox 30 mg or 40 mg otherwise they get heparin sc.

53
Q

INR check on reports.

A

want it between 2-3 x 2 days

54
Q

VTE need reason to start therapy

A

Check the reports section of the eMAR.

55
Q

Orthopedics what anticoagulant to use?

A

Lovenox

56
Q

New anticoagulant pt what 3 things to check?

A

Correct drug
Correct dose
Correct frequency

57
Q

Lovenox dose for PE

A

1 mg/kg q12hr no sub if PE

58
Q

Lovenox dose for non cardiac?

A

1.5 mg/kg max 190 mg/kg

59
Q

Heparin SC dose is

A

change to 5,000 units Q12hr.

60
Q

Heparin when to use?

A

Pt weight less than 45 kg.

CrCl less than 20 ml/min

61
Q

Heparin dose less than 45 kg?

A

5,000 units Q12hr

62
Q

Heparin dose CrCl less than 20 ml/min

A

5,000 units Q12hr

63
Q

Anticoag for Total Hip?

A

Lovenox 40 mg SC Q12hr

64
Q

Anticoag for Hip Fracture?

A

Lovenox 40 mg SC Q12hr

65
Q

Spinal cord injury or total knee, drug, dose, frequency

A

Lovenox 30mg SC Q12hr.

66
Q

Lovenox dose cutoff due to decreased renal function?

A

30 ml/min

67
Q

Lovenox dose in decreased renal function?

A

CrCl 20-29 ml/minute 1 mg/kg. q24h dosing

Pharmacology (14 decks)

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