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Cardio Renal > Anticoagulants > Flashcards

Anticoagulants Flashcards

(63 cards)

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1
Q

Heparin MOA

A

potentiates anti thrombin

decreases pro thrombin –> thrombin

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2
Q

Heparin Route

A

SQ or IV

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3
Q

Heparin Renal Adjustments

A

None

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4
Q

Heparin Body Weight considerations

A

higher body weights may require higher dosing

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5
Q

Heparin Drug Interactions

A

Additive drugs can cause bleeding

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6
Q

Heparin Monitoring

A

anti Xa levels or aPTT

hemoglobin, hematocrit, platelets

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7
Q

Heparin Goal

A

anti Xa level 0.3-0.7 units/ml

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8
Q

LMWH aka…

A

Enoxaparin

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9
Q

LMWH MOA

A

potentiates antithrombin

inactivates factor Xa

(decreases pro thrombin –> thrombin)

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10
Q

LMWH Route

A

SQ or IV (rarely)

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11
Q

Heparin Half Life

A

1-2 hours

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12
Q

LMWH Half Life

A

12 hours

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13
Q

LMWH Renal Adjustments

A

CrCl <30 ml/min

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14
Q

LMWH Body Weight Considerations

A

BMI ≥ 40 kg/m2

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15
Q

LMWH Drug Interactions

A

Avoid additive increased bleeding risk

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16
Q

LMWH Monitoring

A

hemoglobin, hematocrit, platelets

serum creatinine

Anti Xa monitoring in obese, renal dysfunction, or pregnant patients

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17
Q

What class of medication is warfarin?

A

Vitamin K Inhibition

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18
Q

Warfarin MOA

A

Vitamin K Inhibition leading to a reduction in the hepatic synthesis of factors

II, VII, IX, X

and protein C/S by blocking carboxylation

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19
Q

Why does warfarin take effect at steady state?

A

Warfarin inhibits coagulation but also inhibits natural anti coagulation

At SS inhibiting coagulation is greater

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20
Q

Warfarin Route

A

20-60 hours

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21
Q

Warfarin Renal Adjustments

A

none

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22
Q

Warfarin Body Weight Considerations

A

higher body weights may require higher doses

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23
Q

Warfarin Common DDI

A 
Amiodarone
Macrolides
-azoles
Sulfa ABX
Rifampin
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24
Q

Warfarin CYP

A

2C9 major

3A4 minor

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25
Warfarin Monitoring
INR 2-3 | hemoglobin, hematocrit, platelets
26
Warfarin Limitations (5)
1. Frequent INR monitoring 2. Bridging requirements 3. Peri-procedural anticoagulation 4. Drug-drug interactions 5. Drug food interactions
27
Initial warfarin dose for patient starting on warfarin
5 mg daily for 3 days
28
Initial warfarin dose for patient starting on warfarin (more sensitive)
2.5 mg daily for 3 days
29
What makes a patient more sensitive to warfarin?
frail, elderly, undernourished liver disease, kidney disease, HF acute illness on medication that decreases warfarin metabolism
30
When do you check the INR on patient starting warfarin?
Day 4
31
Goal of INR after 4 days after initiation
1.5 - 1.9 | Continue starting dosing
32
Patient starting on warfarin On day 4 INR is < 1.5 What dose do you give them?
7.5 to 10 mg daily for 2-3 days
33
Patient starting on warfarin On day 4 INR is 2-3 What dose do you give them?
2.5 mg daily for 2-3 days
34
Patient starting on warfarin On day 4 INR is 3.1 - 4 What dose do you give them?
1.25 mg daily for 2-3 days
35
Patient starting on warfarin On day 4 INR is > 4 What dose do you give them?
Hold until INR < 3
36
Sensitive Patient starting on warfarin On day 4 INR is < 1.5 What dose do you give them?
5 - 7.5 mg daily for 2 - 3 days
37
Sensitive Patient starting on warfarin On day 4 INR is 1.5 - 1.9 What dose do you give them?
Continue starting dose | 2.5 mg daily for 2-3 days
38
Patient starting on warfarin On day 4 INR is 1.5 - 1.9 What dose do you give them?
Continue starting dose | 5 mg daily for 2-3 days
39
Sensitive Patient starting on warfarin On day 4 INR is 2 - 3 What dose do you give them?
1.25 mg daily for 2 - 3 days
40
Sensitive Patient starting on warfarin On day 4 INR is 3.1 - 4 What dose do you give them?
0.5 mg daily for 2 - 3 days
41
Sensitive Patient starting on warfarin On day 4 INR is >4 What dose do you give them?
Hold until INR < 3
42
Patient already on warfarin | INR <1.5
Increase weekly maintenance dose by 10-20% Consider one time 1.5-2 times the daily dose
43
Patient already on warfarin | INR 1.5 - 1.7
Increase weekly maintenance dose by 5-15% Consider one time 1.5-2 times the daily dose
44
Patient already on warfarin | INR 1.8 - 1.9
No adjust if last 2 INRs in range If need: Increase weekly maintenance dose by 5-10% Consider one time 1.5-2 times the daily dose
45
Patient on warfarin Taking ABX temporarily What dosing do you do?
On time supplemental 1.5-2 times daily dose Resume maintenance dose
46
Patient already on warfarin | INR 3.1 - 3.2
No adjust if last 2 INRs in range If need: Decrease weekly maintenance dose by 5-10%
47
Patient already on warfarin | INR 3.3 - 3.4
Decrease weekly maintenance dose by 5-10%
48
Patient already on warfarin | INR 3.5 - 3.9
Consider holding 1 dose | Decrease weekly maintenance dose by 5-10%
49
Patient already on warfarin | INR ≥4 but ≤10 and no bleeding
Hold until INR below 3 Decrease weekly maintenance dose by 5-20% If patient considered to be a bleeding risk consider oral K
50
Patient already on warfarin | INR >10 and no bleeding
Hold until INR below 3 Give vitamin K orally Decrease weekly maintenance dose by 5-20%
51
Factor Xa Inhibitors
``` Rivaroxaban Apixaban Edoxaban Betrixaban Fonndaparinux ```
52
Apixaban brand name
Eliquis
53
Apixaban route
oral
54
Apixaban A fib dose
5mg BID
55
Apixaban VTE dose
10 mg BID x 1 wek | then 5 mg BID
56
Apixaban half life
12 hours
57
Apixaban renal adjustment
A fib Only 2.5mg BID if 2/3 are met: SCr>1.5 Weight<60 Age>80
58
Apixaban body weight considerations
Okay in those >120 kg or BMI ≥ 40
59
Apixaban drug interactions
Major CYP3A4 substrate
60
Apixaban monitoring
hemoglobin, hematocrit, platelets, serum creatinine
61
Apixaban Pearls
Best DOAC in patients with poor renal function
62
DOACs
``` Apixaban Rivaroxaban Edoxaban Betrixaban Dabigatran ```
63
Patient already on warfarin INR 3.5 Taking drug that temporarily dec. warfarin What do you do?
One time held dose | Consider resumption of prior maintenance dose

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