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Anticoagulation Flashcards

1
Q

Heparin dosing: VTE prophy

A

5000 units SQ q8h (duh)

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2
Q

Heparin dosing: VTE treatment

A

80 units/kg IV bolus, then 18 units/kg/hr infusion

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3
Q

Heparin dosing: ACS/STEMI treatment

A

60 units/kg IV bolus, then 12 units/kg/hr infusion

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4
Q

What body weight should you use for heparin dosing?

A

TBW

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5
Q

Enoxaparin dosing: VTE prophy

A

30mg SQ q12h or 40mg SQ QD

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6
Q

Enoxaparin dosing: VTE prophy in CrCl <30

A

30mg SQ QD

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7
Q

Enoxaparin dosing: VTE, UA/NSTEMI treatment

A

1mg/kg SQ q12h
1.5mg/kg SQ QD in inpatient setting

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8
Q

Enoxaparin dosing: VTE, UA/NSTEMI treatment with CrCl <30

A

1mg/kg SQ QD

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9
Q

Enoxaparin dosing: STEMI treatment in patients <75 years of age

A

30mg IV bolus, then 1mg/kg SQ dose, then 1mg/kg SQ q12h dose

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10
Q

Enoxaparin dosing: STEMI treatment in patients <75 years of age with CrCl <30

A

30mg IV bolus, then 1mg/kg SQ dose, then 1mg/kg SQ QD dose

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11
Q

Enoxaparin dosing: STEMI treatment in patients ≥75 years of age

A

0.75mg/kg SQ q12h, NO BOLUS

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12
Q

Enoxaparin dosing: STEMI treatment in patients ≥75 years of age with CrCl <30

A

1mg/kg SQ QD

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13
Q

What body weight do you use with enoxaparin dosing?

A

TBW

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14
Q

Dalteparin dosing: VTE prophy

A

2500-5000 units

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15
Q

Dalteparin dosing: UA/NSTEMI treatment

A

120 units/kg SQ q12h, max: 10,000 units

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16
Q

Eliquis missed dose instructions

A

Take immediately on the same day, then resume BID dosing. The dose shouldn’t be doubled up

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17
Q

Eliquis dosing: nonvalvular Afib

A

5mg PO BID

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18
Q

Eliquis dosing: nonvalvular Afib renal dosing criteria

A

Decrease to 2.5mg BID if 2/3 criteria met:
Age >80
Weight <60kg
SCr >1.5

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19
Q

Eliquis dosing: DVT/PE treatment

A

10mg BID x7 days, then 5mg BID

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20
Q

Eliquis dosing: DVT/PE extended treatment

A

After >3 months of treatment: 2.5mg PO BID

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21
Q

Eliquis dosing: DVT prophy after knee/hip replacement

A

2.5mg PO BID for 12 days after knee replacement, 35 days after hip replacement

Give 12-24 hours after surgery

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22
Q

Xarelto missed dose instructions: 15mg PO BID

A

Take immediately to make sure you get 30mg/day
AKA: 2, 15mg tabs can be taken at once!

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23
Q

Xarelto missed dose instructions: 10, 15, or 20mg QD

A

Take immediately on same day; if not, just skip

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24
Q

What doses of Xarelto need to be taken with food?

A

Anything ≥15mg

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25
Xarelto dosing: nonvalvular AF (stroke prophy), CrCl >50
20mg PO QD with dinner
26
Xarelto dosing: nonvalvular AF, CrCl 15-50
15mg PO QD with dinner
27
Xarelto dosing: nonvalvular AF, CrCl <15
Don't use
28
Xarelto dosing: treatment of DVT/PE
15mg PO BID x21 days, then 20mg QD with food
29
Xarelto dosing: extended treatment of DVT/PE
After ≥3 months of treatment: 10mg PO QD
30
Xarelto dosing: DVT prophy after knee/hip replacement or acutely ill patients
10mg PO QD x12 days- knee replacement 10mg PO QD x35 days- hip replacement 10mg PO QD x31-39 days- acutely ill Give first dose 6-10 hours after surgery Avoid in CrCl <30
31
Xarelto dosing: reduction in risk of major CVD or CAD/PAD
2.5mg PO BID in combination with low-dose ASA CrCl <15: avoid use
32
Edoxaban missed dose counseling
Take immediately on the same day; don't double up
33
Edoxaban dosing: nonvalvular AF (stroke prophy), CrCl >95
Don't use
34
Edoxaban dosing: nonvalvular AF (stroke prophy), CrCl 51-95
60mg QD
35
Edoxaban dosing: nonvalvular AF, CrCl 15-50
30mg QD
36
Edoxaban dosing: nonvalvular AF, CrCl <15
Don't use
37
Edoxaban dosing: treatment of DVT/PE
60mg PO QD, start after 5-10 days of parenteral anticoagulation CrCl 15-50, body weight is ≤60kg, or on certain P-gp inhibitors: 30mg PO QD CrCl <15: don't use
38
Fondaparinux dosing: VTE prophy, ≥50kg
2.5mg SQ QD
39
Fondaparinux dosing: VTE prophy, <50kg
CI'ed
40
Fondaparinux dosing: VTE treatment, <50 kg
5mg SQ QD
41
Fondaparinux dosing: VTE treatment, 50-100kg
7.5mg SQ QD
42
Fondaparinux dosing: VTE treatment, >100kg
10mg SQ QD
43
Fondaparinux dosing: CrCl 30-50ml
Use caution
44
Fondaparinux dosing: CrCl <30ml
CI'ed
45
Fondaparinux BBW
neuraxial anesthesia
46
Don't give fondaparinux via what route of administration?
IM
47
Dabigatran missed dose counseling
Take immediately UNLESS it's within 6 hours of the next dose, don't double up
48
Dabigatran dosing: nonvalvular AF
150mg PO BID
49
Dabigatran dosing: nonvalvular AF, CrCl 15-30ml/min
75mg PO BID
50
Dabigatran dosing: nonvalvular AF, CrCl <15
avoid use
51
Dabigatran dosing: treatment of DVT/PE and reduction in risk of recurrent DVT/PE
150mg PO BID, start after 5-10 days of parenteral anticoagulation
52
Dabigatran dosing: prophy of DVT/PE after hip replacement surgery
110mg on day 1, then 220mg QD
53
Dabigatran BBW
Patients receiving neuraxial anesthesia or undergoing spinal puncture are at risk of hematomas and subsequent paralysis premature D/C increases risk of thrombotic events
54
Dabigatran CIs
Active bleeding, mechanical heart valves
55
Dabigatran storage
Store in original container at room temperature and discard 4 months after opening
56
Argatroban HIT dosing
2mcg/kg/min, then titrate to target aPTT Max: 10mcg/kg/min
57
Argatroban/bivalirudin dosing: PCI
IV bolus followed by an infusion, all are weight-based Used in patients at risk for HIT
58
When to decrease argatroban dose
Hepatic impairment
59
When to decrease bivalirudin dose
CrCl <30 ml/min
60
Warfarin dosing: healthy outpatients
≤10mg daily for first 2 days, then adjust per INR
61
Warfarin missed dose counseling
Take immediately on same day, don't double up the dose the next day
62
Warfarin dosing: elderly, malnourished, drugs that can increase warfarin levels, heart failure, high risk for bleeding
≤5mg
63
Warfarin INR: when to use a goal of 2-3
most indications: VTE, AF, bioprosthetic mitral valve, mechanical aortic valve, antiphospholipid syndrome
64
Warfarin INR: when to use a goal of 2.5-3.5
mechanical valves
65
Presence of what alleles and polymorphism can increase bleeding risk while taking warfarin?
CYP2C9*2 or *3 alleles, VKORC1 polymorphism
66
How soon should you stop warfarin in patients before they get surgery?
5 days
67
What if the patient getting surgery is taking warfarin but they're at high risk of a bleed?
Stop the warfarin, start them on enoxaparin or heparin
68
If a patient HAS to take enoxaparin before surgery, when do you D/C it?
24 hours before
69
If a patient HAS to take heparin before surgery, when do you D/C it?
4-6 hours before
70
When do you restart warfarin after surgery?
12-24 hours after the procedure when there's adequate hemostasis
71
Duration of VTE treatment: known cause
3 months
72
Duration of VTE treatment: unknown cause
could be indefinite, but definitely more than 3 months
73
Meds to give patients with DVT without cancer
Dabigatran and the DOACs are preferred over warfarin for the firsts 3 months
74
Meds to give patients with DVT AND cancer
DOACs are preferred over other PO meds and Lovenox
75
Med to give patient who had an unprovoked DVT or PE who stopped anticoagulation
ASA
76
Components of CHA2DS2VASc score
CHF HTN Age ≥75 years Diabetes Stroke Vascular disease Age 65-74 Female sex
77
What does the CHA2DS2VASc score measure?
Patient's stroke risk and whether they should be started on anticoagulation
78
CHA2DS2VASc score needed to start anticoagulation
≥2 for males ≥3 for females
79
HASBLED score components
HTN (SBP >160) Abnormal liver or kidney function Stroke history Bleeding tendency/predisposition Labile INR (on warfarin) Elderly (>65 years old) Drugs (ASA, NSAIDs, excess alcohol use)
80
What does the HASBLED score measure?
Patient's risk for a bleed
81
Preferred anticoagulation in pregnancy
Enoxaparin
82
Warfarin to DOAC: when to start Xarelto
When INR <3
83
Warfarin to DOAC: when to start Savaysa
When INR <2.5
84
Warfarin to DOAC: when to start Eliquis
When INR <2
85
Warfarin to DOAC: when to start Pradaxa
When INR <2
86
DOAC to warfarin (except for dabigatran): how to transition
Start parenteral anticoagulant and warfarin at next scheduled dose
87
Pradaxa to warfarin transition
Start warfarin 1-3 days before stopping Pradaxa (determined by renal function- have to look at the package insert for more detail)

NAPLEX (18 decks)

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