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Therapeutics II > Anti-Coagulation Pre-Lecture > Flashcards

Anti-Coagulation Pre-Lecture Flashcards

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1
Q

DVT Risk factors

A
  • obesity
  • > 40
  • family history of DVT
  • Immobilization > 10 days
  • heart failure
  • malignancy
  • MI
  • orthopedic injury
  • oral contraceptive/estrogen use
  • paralysis
  • postoperative state
  • pregnancy
  • prior DVT
  • varicose veins
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2
Q

UFH Key points

A
  • rapid
  • parenteral
  • goal aPTT = 1.5 - 2.5 x control (46 - 70 seconds)
  • Dosing (IV bolus = 80 U/kg, IV infusion = 18U/Kg/hr)
  • AE= bleeding, thrombocytopenia
  • rapid, variable
  • commonly a continuous infusion
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3
Q

HIT management

A
  • stop heparin
  • dont start warfarin until platelets >150,000
  • give alternate LMWH (levirubin, bivalirubin, argatroban, fondaparinux)
  • dont give platelet infusion
  • evaluate for thrombosis
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4
Q

Benefits of LMWH

A
  • good bioavailability = reduced protein bioavailability
  • good predictability
  • smaller molecule = good subQ absorption
  • long t1/2 = once or twice daily dosing
  • less effects on platelets = reduced thrombosis
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5
Q

Enoxaparin Brand

A

Levonox

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6
Q

Enoxaparin (Levonox) Prophylactic Dose Surgery

A

30 mg subQ q12h (surgery)

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7
Q

Enoxaparin (Levonox) Prophylactic Dose Medical

A

40 mg subQ daily (medical)

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8
Q

Enoxaparin (Levonox) Treatment Doses

A
  • 1.0 mg/kg q12h

- 1.5 mg/kg daily

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9
Q

Enoxaparin (Levonox) Key Point

A

Can be used with renal dysfunction (< 30ml/min)

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10
Q

Enoxaparin (Levonox) Renal Dysfunction Doses

A
  • 30 mg subQ DAILY (prophylactic)

- 1.0 mg/kg subQ DAILY (treatment)

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11
Q

Dalteparin (Fragmin) Key Points

A
  • Less common

- Treatment dose common for VTE cancer patients

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12
Q

Dalteparin (Fragmin) prophylactic dose

A

2500 - 5000 U subQ daily

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13
Q

Dalteparin (Fragmin) treatment dose

A

200 U subQ x 30 days QD, 150 U subQ daily (cancer treatment)

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14
Q

Monitoring anti Xa levels for LMWH

A

-consider for children, pregnant, severe kidney dysfunction, obese

  • tx:
  • **BID dosing 0.6 - 1.0 U/ml obtained 4 hours post dose
  • **QD dosing 0.1 - 0.3 U/ml obtained as a trough (checked prior to second dose)
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15
Q

Is monitoring anti Xa levels of LMWH recommended?

A

NOOOOOOO

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16
Q

Fondaparinux Labeled Uses

A
  • TKA
  • THA
  • Hip replacement
  • Abdominal surgery
  • TREATMENT OF DVT OR PE (OFTEN 1ST MED A PT CAN USE)
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17
Q

Fondaparinux prophylactic dose

A

2.5 mg subQ once daily (hip, knee or abdominal surgery)

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18
Q

Fondaparinux treatment dose

A
  • < 50 kg = 5mg subQ QD
  • 50 - 100 kg = 7.5mg subQ QD
  • > 100 kg = 10mg subQ QD
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19
Q

If pt has renal dysfunction < 30ml/min, can a pt use fondaparinux?

A

NOOOOOOOO

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20
Q

Fondaparinux can NOT be used prophylactically in patients with

A

low body weight < 50 kg. Can be used to treat pts < 50 kg

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21
Q

Can Fondaparinux be used to treat HIT

A

YESSSS

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22
Q

Routine monitoring of fondaparinux levels?

A

NOOOOO, but can choose to monitor anti-10a levels similar to LMWH

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23
Q

Fondaparinux safe for pregnancy

A

YES. Category B

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24
Q

IV direct thrombin inhibitors should be associated with

A

USE IN HIT

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25
IV direct thrombin inhibitors
- argatroban - bivalirubin (angiomax) - levirubin
26
Bivalirubin Brand
Angiomax
27
Argatroban KEY points
- if pt has liver dysfunction, adjust dose: * **normal dose = 2 mcg/kg/min * **hepatic dysfunction dose = 0.5 mcg/kg/min - Causes a false elevation of INR * **overlap with warfarin until INR of 4 (most meds overlap until INR of 2) -this medicine can cause hepatic dysfunction
28
For lepirubin, reduce dose
if CrCl is < 60 ml/min
29
LIST ALL NOACS/DOACS
-direct thrombin inhibitor = dabigatran (Pradaxa) - Factor Xa inhibitors: * **rivaroxaban (xarelto) * **apixaban (eliquis) * **edoxaban (savaysa) * **betrixaban (bevyxxa)
30
KEY THING TO REMEMBER ABOUT NOACS/DOACS
WHAT ARE THEY F-ING INDICATED FOR
31
Postoperative Prophylaxis
prevention of a postoperative DVT to PE in pts undergoing knee or hip surgery
32
Non valvular atrial fibrillation
- THIS PIECE OF INFORMATION MUST BE GIVEN TO YOU | - general prevention of stroke and systemic embolism in pts with non-valvular atrial fibrillation
33
Indefinite anticoagulation (secondary prevention of recurrent DVT and/or PE)
- reduction in the risk of a recurrent DVT and/or PE following initial 6 months of treatment - continuing an anti-coag after a pt has been on one for months
34
VTE prophylaxis
-prophylaxis of VTE in adults hospitalized for an acute medical illness who are at risk for thromboembolic complications due to immobility and other VTE risk factors
35
DABIGATRAN INDICATIONS
- POST OPERATIVE PROPHYLAXIS (Hip) - NON-VALVULAR ATRIAL FIBRILLATION - DVT/PE TX
36
RIVAROXABAN INDICATIONS
EVERYTHING - POST OPERATIVE PROPHYLAXIS (Hip) - NON-VALVULAR ATRIAL FIBRILLATION - DVT/PE TX - SECONDARY PREVENTION OF RECURRENT DVT/PE - VTE PROPHYLAXIS
37
APIXABAN INDICATIONS
- POST OPERATIVE PROPHYLAXIS (Hip) - NON-VALVULAR ATRIAL FIBRILLATION - DVT/PE TX - SECONDARY PREVENTION OF RECURRENT DVT/PE
38
EDOXABAN INDICATIONS
- NON-VALVULAR ATRIAL FIBRILLATION | - DVT/PE TX
39
BETRIXABAN INDICATIONS
-VTE PROPHYLAXIS
40
Rivaroxaban also approved for
reduction of risk of major CV events in pts with CAD or PAD
41
Betrixaban other risk factors
- great than or equal to 75 yoa - 60 - 74 yoa with D-dimers >/= 2 ULN - 40 - 59 yoa with D-dimers >/= 2 ULN and a history of VTE or cancer
42
Warfarin Brands
- coumadin | - jantoven
43
Warfarin color is
CONSISTENT
44
Warfarin challenges
- drug drug interactions - narrow therapeutic window - drug and diet interactions - intersubject variablity - difficult to standardize labs - Good PK/PD understanding by both pt/provider
45
Warfarin inhibits the synthesis of vitamin k dependent clotting factors
- 2, 7, 9, 10 | - Protein C + S
46
Warfarin specifically inhibits the
enzyme responsible for cyclic conversion of vitamin K (vitamin K reductase)
47
Warfarin anti-coag effect in
24 hours
48
Warfarin peak effect
72 - 96 hours
49
Warfarin duration of action from a single dose
2 - 5 days
50
Warfarin S enantiomer hepatically metabolized by
2C9, 2C19, 2C18
51
Warfarin R enantiomer hepatically metabolized by
1A2 and 3A4
52
Factor t1/2 considerations
- Factor II (prothrombin) = 60 -100 h - Factor 7 = 4 - 6 h - Factor 9 = 20 - 30 h - Factor 10 = 24 - 40 h
53
VKORC1
reductase enzyme that forms the vitamin K which is converted to clotting factors
54
Who should be tested for warfarin
ALL THREE THINGS NEED TO BE MET: - Insulin naiive - Will get results back before 6th dose - Pt is at a high risk of bleeding (for example on meds that increase bleeding risk)
55
HIGHER THE INR
HIGHER THE BLEEDING RISK
56
Drugs that increase INR
- amiodarone - fluconazole - acute alcohol - metronidazole - fluconazole - ciprofloxacin - bactrim - liver disease - erythromycin
57
Drugs that decrease INR
- chronic use of alcohol - rifampin - cholestyramine - carbamazepine
58
Aspirin and other NSAIDs impact on INR
-these meds increase bleeding HOWEVER do not increase INR
59
How does vitamin K impact warfarin
it reverses warfarin activity
60
Warfarin and chronic alcohol and liver damage
increase in INR
61
Most common antiplatelets
- COX 1 inhibitor = aspirin | - PDE III inhibitor = dipyridamole
62
Consider dipyridamole use in VTE with
concomitant use of warfarin with prosthetic valves
63
Consider ASA in VTE with
CHA2DS2 score 1
64
Bleeding management steps
- discontinue medication - apply manual compression - maintain bp - surgical or radiological intervention - blood products +/- PCC +/- targeted antidotes
65
Consider activated charcoal for bleeding
if there is = 2 hours of bleeding
66
When pt is bleeding and on hemodialysis
use dabigatran only
67
UFH, LMWH reversal agent
protamine sulfate
68
Dabigatran reversal agent
idarucizumab (Praxbind)
69
Factor Xa inhibitors
Andexanet alfa
70
UFH infusion antidote directions
1 mg protamine/100 units UFH given over the past 3 hours
71
LMWH antidote directions
- within 8 hours of last LMWH * **1 mg per 100 anti-factor Xa units * **1 mg per 1 mg enoxaparin - > 8 hours * **0.5 mg per 100 anti-factor Xa units * **0.5 mg per 1 mg enoxaparin
72
Adverse reactions of protamine sulfate antidote
- hypotension - bradycardia - How to fix: slow the infusion (over 1 - 3 minutes), max can give is 50 mg over 10 minutes
73
Idarucizumab (Praxbind) MOA
direct binder to dabigatran (higher affinity than dabigatran to thrombin)
74
Idarucizumab Dose
- 5g IV | - 2 separate 2.5 g doses no more than 15 minutes apart
75
Idarucizumab monitoring
Baseline aPTT, repeat in 2 hours, every 12 hours until normal
76
Andexanet alfa (andexxa) binds and sequesters
rivaroxiban and apixaban
77
Warfarin Bleeding Management dependent on (2 things)
INR and presence/absence of bleeding
78
Warfarin bleeding management: Vitamin K
- Oral (PREFERRED): 5 mg tablets | - Parenteral: Don't exceed 1 mg/min (otherwise will trigger anaphylaxis)
79
Warfarin bleeding management: Fresh Frozen Plasma (FFP)
10 - 15 ml/kg
80
Warfarin bleeding management: Prothrombin Complex Concentrate (PCC)
30 IU/kg (check INR before, 30 - 60 minutes after)
81
Warfarin bleeding management: IF INR 4.5 - 10 AND NO EVIDENCE OF BLEEDING
Avoid vitamin K
82
Warfarin bleeding management: IF INR > 10 AND NO EVIDENCE OF BLEEDING
PO vitamin K
83
Warfarin bleeding management: Major bleeding while on warfarin
PCC preferred over FFP. May add vitamin K 5 - 10 mg as well
84
Warfarin reversal: Rapid (complete, w/in 10 - 15 min)
Prothrombin complex concentrate + IV vitamin K
85
Warfarin reversal: Fast (partial)
Fresh frozen plasma
86
Warfarin reversal: Prompt (w/in 4-6 hours)
IV vitamin K
87
Warfarin reversal: Slow (w/in 24 hours)
PO vitamin K
88
Warfarin reversal: Very slow (3 - 5 days)
Omit warfarin (no vitamin K)
89
VTE prophylaxis options
- unfractionated heparin - LMWH - Factor Xa inhibitors - Vitamin K antagonist (warfarin)
90
Moderate VTE risk
- general surgery pts = UFH, LMWH, Factor Xa inhibitor = continue prophylaxis up to 28 days after hospital discharge - acutely ill medical patients = UFH, LMWH, fondaparinux, rivaroxaban, *BETRIXABAN = For UFH, LMWH, fondaparinux = No specific recommendations for post discharge ~Specific total tx regiments: * **rivaroxaban = 31 - 39 days * **betrixaban = 35 - 42 days
91
High VTE risk
- orthopedic surgery (TKA or THA) - LMWH, fondaparinux, rivaroxaban, apixaban, dabigatran (hip), UFH, or vitamin k antagonist - FDA approved - continue >/= 10 - 14 days post opp (consider up to 35 days)

Therapeutics II (12 decks)

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