Anticoagulation

Question 1

Heparin MOA

Answer 1

Potentiates antithrombin → decreased transformation of prothrombin to thrombin

Question 2

Heparin Route of Administration

Answer 2

SQ (prophylaxis) or IV Continuous Infusion (treatment)

Question 3

Heparin Half-Life

Answer 3

1-2 hours (IV)

Question 4

Heparin Monitoring (efficacy)

Answer 4

Either Anti-Xa levels (~0.3-0.7 units/mL) or aPTT levels (ranges vary per lab) need to be within therapeutic range

Question 5

Low molecular weight hearpin (LMWH) MOA

Answer 5

Potentiates antithrombin → decreased transformation of prothrombin to thrombin AND inactivates factor Xa

Question 6

LMWH Route of Administration

Answer 6

SQ (rarely can be given IV)

Question 7

LMWH Half-Life

Answer 7

~12 hours

Question 8

LMWH Dose Adjustments

Answer 8

CrCl < 30 mL/min

Question 9

LMWH Efficacy Monitoring

Answer 9

Anti-Xa levels only in specific populations - obese, renal dysfunction, pregnant

Question 10

List the Direct acting oral anticoagulants

Answer 10

Apixaban (Eliquis), Rivaroxaban (Xarelto), Edoxaban (Savasya), Dabigatran (Pradaxa)

Question 11

List Factor-Xa inhibitors

Answer 11

Apixaban (Eliquis), Rivaroxaban (Xarelto), Edoxaban (Savasya)

Question 12

List Factor IIa inhibitors

Answer 12

Dabigatran (Pradaxa) (Direct thrombin inhibitor)

Question 13

Warfarin indications

Answer 13

1. Valvular Afib
2. Mechanical heart valves
3. Some hypercoagulable states

Question 14

Warfarin MOA

Answer 14

Vitamin K antagonist->decreases hepatic synthesis of factors 2,7,9, and 10, protein C and S by blocking carboxylation

Question 15

Warfarin route of administration

Answer 15

Oral

Question 16

Warfarin half-life

Answer 16

20-60 hours~

Question 17

Warfarin DDI

Answer 17

CYP1A2, CYP2C19, and MAJOR (CYP2C9 and (CYP3A4)

1.Amiodarone, 2.Macrolide Antibiotics (Azithromycin, Erythromycin), 3.-azole antifungals (fluconazole), 4.Sulfa antibiotics (Bactrim), 5. Rifampin

Question 18

Warfarin monitoring parameters

Answer 18

INR 2-3 (1 considered normal)
Hgb, Hct, platelets

Question 19

What is the brand name of Apixaban?

Answer 19

Eliquis

Question 20

Apixaban route of administration

Answer 20

oral

Question 21

Apixaban AFib Dosing

Answer 21

5 mg twice daily

Question 22

Apixaban VTE Dosing

Answer 22

10mg twice daily x 1 week, then 5 mg twice daily

Question 23

Apixaban dose adjustment

Answer 23

Only for AFib! Adjust dose to 2.5mg BID if 2/3 criteria are met:

• SCr > 1.5
• Weight < 60 kg
• Age > 80 years old

Question 24

Apixaban DDI

Answer 24

Major substrate of CYP3A4

Question 25

Rivaroxaban brand name

Answer 25

Xarelto

Question 26

Rivaroxaban route of administration

Answer 26

PO

Question 27

Rivaroxaban AFib Dosing

Answer 27

20 mg daily WITH FOOD

Question 28

Rivaroxaban VTE Dosing

Answer 28

15 mg twice daily x 21 days then 20 mg daily WITH FOOD

Question 29

Rivaroxaban dose adjustment

Answer 29

Afib Only: CrCl 15-50 mL/min then 15 mg daily with food Avoid use CrCl \< 15 mL/min

Question 30

Rivaroxaban DDI

Answer 30

Major substrate of CYP3A4

Question 31

Brand name of Edoxaban

Answer 31

Savaysa

Question 32

Edoxaban route of administration

Answer 32

Oral

Question 33

Edoxaban dose AFIB

Answer 33

60 mg PO QD

Question 34

Edoxaban dose in VTE

Answer 34

After 5 days of parenteral anticoagulation: \>60kg = 60 mg PO QD ≤60kg = 30 mg PO QD

Question 35

Edoxaban renal dose adjustment

Answer 35

AFIB: 15-50 ml/min: 30 mg PO QD

Question 36

Edoxaban use caveat (Renal)

Answer 36

Only use in patients with moderate kidney function CrCl 15-95 ml/min

Question 37

Fondaparinux brand name

Answer 37

Arixtra

Question 38

Fondaparinux route of administration

Answer 38

Parenteral: SQ and IV

Question 39

Avoid fondaparinux in these populations

Answer 39

CrCl \< 30 mL/min Weight \< 50 kg

Question 40

Dabigatran route of administration

Answer 40

Oral

Question 41

Dabigatran AFib Dosing

Answer 41

150 mg twice daily

Question 42

Dabigatran VTE Dosing

Answer 42

5 days parenteral then 150 mg twice daily

Question 43

Dabigatran renal adjustment

Answer 43

_Afib:_ CrCl 15-29 mL/min 75 mg twice daily Avoid CrCl \< 15 mL/min _VTE:_ Avoid CrCl \< 30 mL/min

Question 44

Dabigatran weight consideration

Answer 44

Avoid \> 120 kg, BMI ≥ 40 kg/m²

Question 45

Bivalirudin MOA

Answer 45

Direct thrombin inhibitor

Question 46

Bivalirudin route of administration

Answer 46

Continuous IV infusion

Question 47

Bivalirudin half-life

Answer 47

10-24 minutes

Question 48

Argatroban MOA

Answer 48

Direct Thrombin Inhibitor

Question 49

Argatroban Route of Administration

Answer 49

Continuous IV Infusion

Question 50

Argatroban Half-Life

Answer 50

39-51 minutes

Question 51

Heparin-Induced Thrombocytopenia (HIT) Risk Factors

Answer 51

1. Source: Bovine \> Porcine 2. UFH \> LMWH 3. IV \> SQ 4. Surgical patients \> Medical/Obstetric 1. Longer exposure = higher risk

Question 52

4T Score Components

Answer 52

1. Thrombocytopenia 2. Timing 3. Thrombosis 4. Other Cause

Question 53

HIT is an indication for therapeutic anticoagulation (T/F)

Answer 53

TRUE!

Question 54

Components of CHA₂DS₂VASc Score

Answer 54

C: Congestive HF H: HTN A: Age \> 75 years (2 pts) D: Diabetes S: Stroke/TIA/Systemic Embolism (2 pts) V: Vascular Disease A: 75-74 years Sc: Female

Question 55

Anticoagulation indicated in men with a CHA₂DS₂VASc Score ≥ \_\_\_

Answer 55

2

Question 56

Anticoagulation indicated in women with a CHA₂DS₂VASc Score ≥ \_\_\_

Answer 56

3

Question 57

HASBLED Componenets

Answer 57

H: HTN - SBP \> 160 mm Hg A: Abnormal liver/kidney function (1 each) S: Stroke history B: Bleeding history L: Labile INR E: Elderly \> 65 years D: Drug/Alcohol abuse (1 each)

Question 58

Lenient Rate Control HR Goal

Answer 58

\< 110 bpm

Question 59

Patients who qualify for Lenient Rate Control

Answer 59

Asymptomatic **AND** EF \> 40%

Question 60

Strict Rate Control HR Goal

Answer 60

\< 80 bpm

Question 61

Patients who qualify for Strict Rate Control

Answer 61

Symptomatic **OR** EF ≤ 40%