Anticoags, antiplatelet and DOACs Flashcards Preview

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Flashcards in Anticoags, antiplatelet and DOACs Deck (64):
1

Unfractionated heparin class

Anticoagulants

2

Fractionated LMW Heparin (Lovenox) class

Anticoagulants

3

Warfarin (Coumadin) class

Anticoagulants

4

Clopidogrel (Plavix) class

Antiplatelet Drugs

5

ASA class

Antiplatelet Drugs

6

Abixaban (Eliquis) class

DOACs (direct oral anti-coagulants)

7

Dabigatran (Pradaxa) class

DOACs (direct oral anti-coagulants)

8

Rivaroxaban (Xarelto) class

DOACs (direct oral anti-coagulants)

9

Heparin Sodium (UFH) route

SQ , IV

10

UFH onset

(IV) immediate; SQ (20 min); 1⁄2 life 1.5hrs

11

UFH indications

Thromboembolism prophylaxis/treatment, Acute coronary syndromes, patency of catheters via continuous infusion or line flushing, DIC

12

UFH MOA

Antithrombin II catalyst which binds and inactivates factors IIa and Xa

13

UFH AE

Bleeding, hypersensitivity, *transient vs (HIT) thrombocytopenia, chest pain, thrombosis, vasospasm, chills, headache, peripheral neuropathy, GI effects (N/V/constipation)

14

UFH CI

HIT hx, IM injection, active bleeding

15

UFH pearls

Give SQ dosing within 2hrs of operation for VTE prophylaxis

VTE prophylaxis dosing every 8-12hrs, SQ

In a patient on continuous IV heparin gtt (ie for inpatient clot tx) monitor levels and adjust to therapeutic dosing via hourly aPTT

For patients on heparin gtts, can turn off AM before surgery (easy on, easy off due to short 1⁄2 life) then restart immediately after surgery

aPTT monitoring is NOT indicated for VTE prophylaxis dosing (8-12 hr SQ dosing)

16

Enoxaparin (Lovenox) route

SQ

17

Enoxaparin (Lovenox) onset and peark

3-5hrs, duration: 12hrs

18

Enoxaparin (Lovenox) indications

Acute coronary syndrome (unstable angina, NSTEMI/STEMI), DVT
prophylaxis/treatment, bridge therapy (off-label use for mechanical valves,
interruption of Vit K antagonist therapy), VTE during pregnancy (off-label)

19

Enoxaparin (Lovenox) MOA

acts as anticoagulant by optimizing inhibition of clotting factors. Has small
effect on aPTT and strongly inhibits factor Xa over factor IIa

20

Enoxaparin (Lovenox) AE

Bleeding, anemia. *US Boxed Warning: Epidural and spinal
hematomas w/ neuroaxial anesthesia and LP. Peripheral edema, confusion,
nausea, fever, HIT

21

Enoxaparin (Lovenox) CI

Hypersensitivity to enoxaparin, heparin, hx of HIT, pork
products, or benzyl alcohol, active major bleeding, and thrombocytopenia w/ in vitro testing for antiplatelet antibodies

Precaution in elderly

22

Enoxaparin (Lovenox) pearls

Generally, once a day dosing for VTE prophylaxis. Some ortho surgeries, twice daily for VTE prophylaxis

When using to treat a DVT, dosing = 1mg/Kg twice daily, SQ

Serum levels are not monitored with aPTT

More expensive than unfractionated heparin

Must increase dosing for BMI > 40mg/m2

23

Warfarin (Coumadin) route

PO

24

Warfarin (Coumadin) indications

Prophylaxis and treatment of VTE and embolic complications related to Afib (valvular and non-valvular), mechanic prosthetic heart valves, post MI

25

Warfarin (Coumadin) MOA

Vitamin K antagonist

26

Warfarin (Coumadin) AE

US Boxed Warning: *Potentially fatal bleeding

27

Warfarin (Coumadin) CI

Pregnancy (teratogenic), any active bleed, hypersensitivity, recent surgery of the eye or CNS, blood dyscrasias, *patients prone to non-compliance, falls

Precaution in renal disease

28

Warfarin (Coumadin) pearls

Once daily dosing

D/C 5 days before surgery, consider bridging based on VTE risk, resume 12-24 hrs after surgery

The goal of anticoagulant therapy is to prevent further extension of an already formed thrombus and to prevent secondary thromboembolic complications

Antibiotics effect efficacy, must monitor INR more closely

Only consider in a post 1st trimester, pregnant patient with a mechanical heart
valve (high risk of stroke)

Avoid foods high in Vit K (green leafy vegetables, green tea, cooking oils)

PT/INR monitoring: outpatient usu. weekly, if dose changes usu. Q 2-3 days

29

Warfarin onset and peak

24-72 hrs, Peak: 5-7 days, expect INR to raise q36-72 hrs

30

Clopidogrel (Plavix) route

PO

31

Clopidogrel (Plavix) indications

acute coronary syndrome, recent MI/stroke, unstable angina,
established peripheral arterial disease, CAD, cardioembolic stroke, carotid artery
stenting (off-label)

32

Clopidogrel (Plavix) MOA

inhibits platelet aggregation by inhibiting adenosine diphosphate (ADP)-
induced pathway

33

Clopidogrel (Plavix) AE

*GI bleed, minor to major hemorrhage, itching, rash, URIs, chest pain,
headache, arthralgia, pain, bruising, diarrhea

34

Clopidogrel (Plavix) CI

*US Box warnings: dependent on CYP P450 (CYP2C19) for
activation; poor CYP2C19 metabolizers should use another platelet inhibitor

Hypersensitivity, active pathologic bleeding

Precaution in kidney disease

35

Clopidogrel (Plavix) pearls

D/C 5 days before surgery

Severe side effects include severe neutropenia, TTP, acute liver failure, aplastic
anemia, hepatitis, and agranulocytosis

Off label uses for ASA allergic patients

Avoid with grapefruit juice, decreases efficacy of drug

36

Apixaban (Eliquis) route

PO

37

Apixaban (Eliquis) indications

Stroke prevention in A-Fib: CHA2D2S-VASc ≥ 2 or consider at 1, if other than female sex

Active DVT/PE or risk of DVT/PE from recent surgery

38

Apixaban (Eliquis) MOA

electively blocks active site of factor Xa, inhibiting blood coagulation

Metabolized in the kidney and liver

39

Apixaban (Eliquis) AE

*US Boxed Warnings: Increased thrombotic event risk when premature D/C, epidural/spinal hematoma risk and LP. Bleeding, anemia, nausea, thrombocytopenia, hypersensitivity rxn or syncope

40

Apixaban (Eliquis) CI

Allergy, active major bleeding, Child-Pugh Class C, acute PE with hemodynamic instability, requiring thrombolysis or pulmonary embolectomy

Caution with age > 80, wt < 60 kg, Cr >1.5, spinal puncture, epidural or prosthetic heart valve

41

Apixaban (Eliquis) pearls

Best option of class for renal concerns

Twice daily dosing

Ok to d/c 2-3 days before general surgery, D/C 5-7 days prior to spinal procedure

Bridge Tx not indicated

42

Rivaroxaban (Xarelto) route

PO

43

Rivaroxaban (Xarelto) indications

Stroke prevention in A-Fib: CHA2D2S-VASc ≥ 2 or consider at 1, if other than female sex

Active DVT/PE or risk of DVT/PE from recent surgery

44

Rivaroxaban (Xarelto) MOA

Selectively blocks active site of factor Xa, inhibiting blood coagulation

45

Rivaroxaban (Xarelto) AE

*US Boxed warnings: Increased thrombotic event risk when premature D/C, epidural/spinal hematoma risk w/ neuroaxial anesthesia and LP. Bleeding, back pain, pruritus, ALT elevation, agranulocytosis, thrombocytopenia, Steven-Johnson syndrome, hepatitis

46

Rivaroxaban (Xarelto) CI

Allergy, active major bleeding, Child-Pugh Class B or C, CrCl <30, Acute PE with hemodynamic instability, requiring thrombolysis or pulmonary embolectomy or pregnancy. Caution with CrCl 30-50 DVT prophylaxis, CrCl 15-50 for thromboembolism/stroke prophylaxis, elderly, Cr >1.5, spinal puncture, epidural or prosthetic heart valve

47

Rivaroxaban (Xarelto) pearls

Once daily dosing available

Ok to d/c 2-3 days before general surgery, D/C 5-7 days prior to spinal procedure

Bridge Tx not indicated

48

Dabigatran (Pradaxa) route

PO, IV

49

Dabigatran (Pradaxa) indications

Stroke prevention in A-Fib: CHA2D2S-VASc ≥ 2 or consider at 1 , if other than female sex

Active DVT/PE or risk of DVT/PE from recent surgery

*Not for initial presentation presentation of DVT/PE

50

Dabigatran (Pradaxa) MOA

Directly, reversibly inhibits thrombin

Product metabolized in the kidney

51

Dabigatran (Pradaxa) AE

*US Boxed warnings: Increased thrombotic event risk with premature D/C, epidural/spinal hematoma risk with neuroaxial anesthesia and LP. Bleeding, *dyspepsia, gastritis, GI bleeding, thrombocytopenia, hypersensitivity rxn or anaphylaxis

52

Dabigatran (Pradaxa) CI

Allergy, active major bleeding, or mechanical heart valve. Caution with age > 75, spinal puncture, epidural or prosthetic heart valve

53

Dabigatran (Pradaxa) pearls

*Only DOAc with reversal agent, Idarucizumab (Praxbind)

Twice a day dosing

D/C 5-7 days prior to spinal procedure, 2-3 days before general surgery

Bridge Tx not indicated

54

DOAC Advantages

Lower all cause mortality

No lab monitoring

Less diet and drug interactions

No bridge therapy pre-op

55

DOAC Disadvantages

Some are 2x/day dosing

Expensive!

Avoid in: Prosthetic valve, pregnancy, BMI > 40kg/m2

Antidote only for Pradaxa

56

Heparin & warfarin Advantages

Cheap

Heparin products ok for
pregnancy

Available antidotes

Preferred anticoagulant for renal impaired

Missed doses, less harmful

Warfarin: once daily

57

Heparin & warfarin Disadvantages

Increased bleeding complications

Warfarin: teratogenic, CI in pregnancy

58

Reversal Agents for UFH and Fractionated LMW Heparin (Lovenox)

protamine sulfate

59

Reversal Agents for Warfarin (Coumadin)

vitamin K, FFP

60

Anticoagulants that have reversal agents

UFH, Fractionated LMW Heparin (Lovenox) and Warfarin (Coumadin)

61

DOACs (direct oral anti-coagulants) with reversal agents

Dabigatran (Pradaxa)

62

Dabigatran (Pradaxa) reversal agent

PRAXBIND

63

What can you consider as a reversal agent if a pt was given Clopidogrel (Plavix)

platelet transfusion

64

What can you consider as a reversal agent if a pt was given ASA

platelet transfusion