anticoags Flashcards

Question

What should Enoxaparin NOT be used in

Answer 1

patients with cancer | -it can be used as prophylaxis in hip/knee replacement, abd surgery, acute med illness, and DVT Tx

Answer 2

DVT/PE treatment Knee replacement surgery -can be used in hip replacement, abd surgery, acute med illness, and VTE cancer prophylaxis

Answer 3

``` Large acidic polysaccharide polymers Parenteral admin site of action: blood Onset: rapid, minutes MOA: binds AT-III and inactivates factor IXa, Xa, XII Monitoring: aPTT for UFH Antidote: protamine IV for UFH Use: acute, over days Use in pregnancy: yes! ```

Answer 4

``` Small lipid soluble molecule PO site: Liver Onset: slow (days); limited by halflives of normal factors MOA: interferes w/ synthesis of vitamin K dependent clotting factors (II, VII, IX, X) Monitor: PT/INR Antidote: vitamin K if Sx. plasma Use: chronic, wk-mo Pregnancy: No! it is teratogenic* ```

Answer 5

rat poison!

Answer 6

Inhibits VK poxide reductase= interferes with synthesis of functional VK= No VK dependent clotting factors -Used in VTE, PE, preventing clots in AFIB or cardiac valve replacement PO has delayed onset and offset activity

Answer 7

Bleeding! can use VK to reverse effects thrombosis early in therapy is 2/2 protein C deficiency *Monitor PT/INR

Answer 8

CYP450 inducers: decreases effect | CYP450 inhibitors: increases effect

Answer 9

Factor VII!!! (4-6 hour half life) Then protein C (9 hour half life) Lastly Protein S (60 hr half life)

Answer 10

``` Hypersensitivity Hemorrhagic tendencies recent eye surgery or CNS lumbar block anesthesia or traumatic surgery malignant HTN Adherence concerns (need to monitor) ```

Answer 11

Apixaban (eliquis) Betrixiban Edoxaban Rivaroxaban (xarelto)- most bioavailable (80%) Dabigatran: prodrug! converted in liver to active form. most renally excreted drug (80%)

Answer 12

Bind active site of Factor Xa and inhibit enzyme action -Used for VTE, PE, preventing stroke in AFib pts Fixed PO dose

Answer 13

bleeding! no specific reversal agent | Do not need to monitor these patients or dose adjust, but can check factor Xa test

Answer 14

Dabigatran (pradaxa) | Edoxaban (also do NOT use this in extended VTE Tx; >6 months)

Answer 15

When using for extended VTE Tx (>6 months), give the dose WITH food! The only time you have the option, w/ or w/o food, is short term VTE prophylaxis after ortho surgery

Answer 16

Apixaban! | It has the lowest renal excretion, at only 25%

Answer 17

Full dose anticoag therapy is recommended for min. 3 months after DVT or PE Patients at high risk may benefit from extended Tx Low dose DOAC is safer than full dose traditional anticoag for extended Tx *Consider low dose DOAC for patients requiring long term VTE prevention after 3-6 months of acute Tx

Answer 18

Dabigatran: Praxbind Rivaroxiban, Apixaban, LMWH: Andexanet (FDA approved) Ciraparantag: UFH, LMWH, Rivaroxaban, Apixaban, Edoxaban, Dabigatran

Answer 19

``` Day 0-7: Apixaban high dose Wk 2-6 mo: Apixaban med dose >6 months: Apixiban low dose OR Day 0-21: Rivaroxaban 15mg Day 22->6 mo: Rivaroxaban 20mg ```

Answer 20

Day 0-5: UFH, LMWH, or Fondaparinux | Day 5- >6mo: Dabigatran or Edoxaban

Answer 21

Day 0-6: UFH, LMWH, or Fondaparinux | Day 0- >6mo: Warfarin PO daily

Answer 22

Initial duration to effectively treat acute 1st episode of VTE: 3 months This reduced recurrent VTE risk

Answer 23

2-3 | Except if with a mechanical valve: 2.5-3.5 (lifelong therapy)

Answer 24

``` Please Let Granny Brown Bring Peaches To Your Wedding Pink -1 Lavender -2 Green -2.5 Brown -3 Blue -4 Peach -5 Teal -6 Yellow -7.5 White -10 ```

Answer 25

Day 1: 5mg 2-3 days later: if INR <1.5, continue at 5. >3, hold and recheck next day 5-7 days later: if INR <1.5, increase to 7.5-10. If >3, reduce to 0-.25mg

Answer 26

Every 2-3 days until INR in therapeutic range on 2 consecutive checks Every week until 2+ checks in therapeutic range Every 2 weeks until 2+ checks in therapeutic range Every 4 weeks when dose is stable

Answer 27

<1.5: increase 10-20% TWD 1.5-1.9: increase 5-10% total weekly 2-3: no change 3-1.4: decrease 5-10% total weekly 4.1-5: hold 1-2 doses and decrease 10% total weekly -If goal is 2.5-3.5, hold 1-2 doses and decrease 10% if INR is 4.6-5

Answer 28

After 1 week if starting or stopping interacting med, changing diet or activity level Every 1-2 wks if 5-10% dose adjustment needed Every 4 wks if maintained on same stable dose <3 mo. Every 6-8 weeks if pt on same stable dose 3+ mo Every 12 weeks if pt on same stable dose for 6+ mo

Answer 29

``` Increased INR response Baseline INR >1.5 65+ y/o ABW <45kg (actual < ideal) Malnourished/NPO >3 days Hypoalbuminemia Chronic diarrhea Significant dug interactions Decompensated HF Increased bleeding risk Thrombocytopenia Cirrhosis/total bili >2.4 Hx alcohol abuse ESRD GI bleed in past 30 days Surgery in the past 2 weeks IC bleed in past 30 days ```

Answer 30

dose adjustments should be made on current total weekly dose consider trends in INR when making management decisions consider pt ht, wt, age with dose requirements Consider repeating INR in same day if value is very diff. than expected Consider no dose adjustments for INR on low end or high end, retest in 1-2 weeks Consider no dose adjustments for INR above or below therapeutic range by 0.5 or less. retest in 1-2 wks Monitor more frequently in first month of initiation Consider extending monitoring more frequently in first 3 mo. of in-range INR CoaguCheck XS machine is only accurate for INR 0.8-8

Answer 31

Recommend against use of VK Hold 1-2 doses, check INR in 24 hrs Resume lower dose when INR in range

Answer 32

Give VK 2.5-5mg Hold 2 doses, check INR in 24 hrs Repeat VK prn Resume lower dose of warfarin when INR is in range

Answer 33

Holding warfarin 1 dose drops INR by appx. 1

Answer 34

Need min. 5 days of warfarin therapy and pt INR in goal range for min 24 hours before you can d/c Lovenox day 1: initiate lovenox and warfairn day 4: check INR. cont or adjust dose if needed day 6: check INR. cont or adjust dose if needed day 7: check INR. dc lovenox if INR in goal range for 24 hrs, or continue lovenox until it occurs

Answer 35

``` heart valve replacement CABG neuro, urologic, head/neck, abd, or breast cancer laminectomy kidney biopsy transurethral prostate resection polypectomy, variceal Tx, biliary sphincterotomy, pneumatic dilation PEG placement EGD guided FNA multiple tooth extractions vascular and general surgery Any major op lasting >45 min ```

Answer 36

4 days before surgery: dc warfarin 3 days before surgery: initiate LMWH 2 days before surgery: check INR 1 day before surgery: dc LMWH 1 day after surgery: resume warfarin 2 days after surgery: resume LMWH for low bleed risk procedure 3 days after surgery: resume LMWH for high bleed risk procedure

Answer 37

dc warfarin and start Dabigatran or Eliquis when INR <2 | dc warfarin and start Rivaroxaban when INR <3

Answer 38

Rivaroxaban: no data available Dabigatran: CrCl >50, start warfarin 3 days before dc dabigatran CrCl 30-50, start warfarin 2 days before dc CrCl 15-30, start warfarin 1 day before dc

Answer 39

Extended therapy: at periodic intervals (ex. yearly) w/ leg DVT or PE on warfarin: maintain INR 2-3 w/ leg DVT or PE, no cancer, no DOAC: warfarin preferred

Answer 40

If home circumstance is adequate, initial Tx at home is better Early ambulation is suggested over bed rest Anticoag Tx alone is better than cath thrombolysis if DVT is acute and proximal LE If acut and Sx leg DVT, do not use compression stockings

Answer 41

Alteplase, Reteplase Tenecteplase Streptokinase Urokinase

Answer 42

convert plasminogen to plasmin which causes breakdown of clots -Good for MI, DVT, PE, and ischemic stroke (t-PA) Alteplase, Reteplase convert fibrin bound plasminogen targeting clots

Answer 43

Ischemic chest discomfort lasting 20+ min, onset <12 hours ST elevation in 2 contiguous leads (2+mm in men, 1.5+mm in women in V2-3 -OR- 1+mm in all other leads) New LBBB

Answer 44

``` active internal bleeding (not menses) previous IC hemorrhage Ischemic stroke w/in 3 mo known IC neoplasm known structural cerebral vascular lesion (AVM) suspected aortic dissection significant closed head/facial trauma w/in 3 mo IC or intraspinal surgery w/in 2 mo severe uncontrolled HTN Use of streptokinase w/in 6 mo ```

Answer 45

``` *Aspirin! class 1 recc. for both Clopidogrel in addition to ASA is class 1 recc for both PCI in both is also a class 1 Prasugrel added to ASA is a class I for both Can also add Ticagrelor, or Cangrelor to ASA therapy ```

Answer 46

``` UFH is a class I in both Enoxaparin is a class I in both Bivalirudin is a class I for both Fondaparinux is a class I for both ```

Answer 47

``` Fibrinolytic Tx: STEMI w/in 12 hrs, class I. NSTEMI, class III GPI inhibitors: NSTEMI class I (for abciximab). STEMI class IIa (for abciximab) Nitroglycerin: class I for both ```

Answer 48

``` BB: class I for both (PO). class III for IV CCB: NSTEMI class I. Diltiazem for NATEMI/AMI class III ACE-I: class I for both ARB: class I for both Aldosterone antag: class I for both Morphine: class IIb for both if CP persists after drug Tx Statins: class I for both ```

Answer 49

ASA: inhibits thromboxane A2 synthesis by irreversibly inhibiting COX-1 Clopidogrel, prasugrel: irreversibly block P2Y12 (ADP receptor on PLT surface) Cangrelor, ticagrelor: reversibly ind P2Y12 receptor Abciximab, Eptifibatide, tirofiban: block fibrinogen and vWF binding to GP IIb/IIIa= inhibit final common pathway of platelet aggregation Vorapaxar: targets PAR-1 (major thrombin receptor) and inhibits thrombin mediated platelet activation

Answer 50

Bivalirudin, Desirudin, Argatroban Bind thrombin's active site and inhibit it's enzymatic action Used as anticoag in patients w/ heparin induced thrombocytopenia

Answer 51

Bleeding! | monitor aPTT

Answer 52

Bivalrudin! No renal or liver clearance, and shorter half life so easier to control -Desirudin is renally cleared, Argatroban has hepatic metabolism

anticoags Flashcards

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