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Anticoagulation Flashcards

1
Q

HAS-BLED

A

Hypertension (SBP >160)
Abnormal renal or hepatic function
Stroke history
Bleeding tendency or predisposition
Labile INR
Elderly (>65)
Drug or alcohol excess

Renal = chronic dialysis, renal transplant, SCr >= 2.26

Hepatic = Chronic hepatic disease, bilirubin >2x ULN, AST/ALT/ALP >3x ULN

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2
Q

Initiate warfarin 2-3mg in these groups

A

-Advanced age
-Low body weight (<45kg)
-Drug interactions
-Malnutrition
-Heart failure
-Hyperthyroid
-Low albumin, liver disease
-Ethnic groups (Asian)

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3
Q

Ideal Time in Therapeutic Range (TTR)

A

65-70%

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4
Q

S warfarin metabolism, common DI

A

CYP2C9 > CYP3A4

metronidazole, bactrim, fluconazole, isoniazid, fluoxetine, sertraline, amiodarone

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5
Q

R warfarin metabolism, common DI

A

CYP1A2, CYP3A4 > CYP2C19

clarithromycin/erythromycin, azoles, fluoxetine, amiodarone, cyclosporine, sertraline, grapefruit juice, FQs, PIs, diltiazem/verapamil, isoniazid, metronidazole

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6
Q

Dabigatran dosing, adjustment AFIB

A

Standard: 150mg BID

CrCl 15-30 ml/min: adjust to 75mg BID
CrCl 30-50 ml/min IN combo with ketoconazole or dronaderone: adjust to 75mg BID

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7
Q

Avoid dabigatran

A

CrCl <15 ml/min

Dialysis

CrCl 15-30 ml/min IN COMBO with verapamil, ketoconazole, dronedarone, clarithromycin

P-gp inducers (rifampin)

Chemo agents

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8
Q

Chemo agents that interact with all DOACs

A

Vinblastine, doxorubicin, imatinib, crizotinib, vandetanib, sunitinib, abiraterone, enzalutamide

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9
Q

Dabigatran metabolism

A

Renal, interactions occur w/ P-gp

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10
Q

Rivaroxaban dosing, adjustment AFIB

A

Standard: 20mg daily with food

CrCl 15-50 ml/min or dialysis: adjust to 15mg daily with food

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11
Q

Avoid rivaroxaban

A

Strong CYP3A4 and P-gp inducers or inhibitors

Chemo agents

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12
Q

Apixaban dosing, adjustments AFIB

A

Standard: 5mg BID

Adjust to 2.5mg BID:
If 2/3 criteria met (>= 80 y/o, weight <=60kg, SCr >= 1.5),
Use with strong CYP3A4 and P-gp inhibitors
Dialysis

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13
Q

Avoid apixaban

A

Strong CYP3A4 and P-gp inducers

Strong CYP3A4 and P-gp inhibitors (dose reduce or avoid if already on 2.5mg BID)

Chemo

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14
Q

Edoxaban dosing, adjustment AFIB

A

Standard: 60mg daily

CrCl 15-50 ml/min: adjust to 30mg daily

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15
Q

Avoid edoxaban

A

CrCl > 95 ml/min

CrCl < 15 ml/min

Dialysis

P-gp inducers

Chemo

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16
Q

Dabigatran to Warfarin conversion

A

CrCl >= 50 = initiate warfarin 3 days before discontinuing

CrCl 31-50 = initiate warfarin 2 days before discontinuing

CrCl 15-30 = initiate warfarin 1 day before discontinuing

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17
Q

Warfarin to Dabigatran

A

D/C warfarin, initiate dabigatran when INR <2.0

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18
Q

Dabigatran to Parenteral Anticoagulant

A

Wait 12 hr (CrCl > 30) or 24 hr (CrCl <30) after dabigatran to initiate parenteral

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19
Q

Parenteral Anticoagulant to Dabigatran

A

Initiate dabigatran 0-2 hours before next dose of parenteral dose due OR when UFH is discontinued

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20
Q

Rivaroxaban or Apixaban to Warfarin

A

D/C rivaroxaban. Start parenteral anticoagulant and warfarin as bridge

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21
Q

Warfarin to Rivaroxaban

A

D/C warfarin, start rivaroxaban when INR <3.0

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22
Q

Parenteral Anticoagulant to Rivaroxaban

A

Initiate rivaroxaban 0-2 hours before next scheduled administration

If on UFH, D/C heparin and start rivaroxaban at the same time

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23
Q

Warfarin to Apixaban

A

D/C warfarin and start apixaban when INR <2.0

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24
Q

Parenteral Anticoagulant to Apixaban

A

D/C anticoagulant and start apixaban at usual time of next dose

If on UFH infusion, DC infusion and start apixaban at same time

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25
Edoxaban to Warfarin
If on edoxaban 60mg: reduce to 30mg and start warfarin at the same time. Once daily INR >=2.0, d/c edoxaban If on edoxaban 30mg: reduce to 15mg and follow same as above OR D/C edoxaban and bridge warfarin with parenteral anticoag
26
Warfarin to Edoxaban
D/C warfarin and start edoxaban when INR <= 2.5
27
Parenteral Anticoagulant to Edoxaban
D/C anticoagulatn and start edoxaban at next scheduled time If UFH, d/c infusion and start edoxaban 4 hours later
28
Trial results for DOAC vs Warfarin in AFIB
-Noninferior for stroke/stroke embolism -ALL DOACS significantly lower rate of hemorrhagic stroke -Dabigatran only DOAC w/ sig reduction of ischemic stroke -Apixaban/edoxaban had sig reduction in major bleeding -Apixaban only agent to show sig reduction in mortality compared to warfarin
29
Avoid/Caution DOACs in AFIB
Pregnancy Breastfeeding Severe hepatic dysfunction (Child-Pugh B or C) Antiphospholipid syndrome Bariatric surgery (Variable PKs) Caution in obesity (BMI >40) or low body weight
30
Bioprosthetic valve placement AND AFIB anticoag
-Afib onset > 3 months after valve = DOAC -Afib onset <3 moths after valve = warfarin
31
Valve replacements when INR 2.5-3.5 recommended
-Aortic mechanical valve with risk factors for thromboembolism, older generation valve -On-X aortic valve with no risks for TE (for 3 months, then reduce INR to 1.5-2.0 w/ aspirin) -Mitral mechanical valve -Aortic & mitral heart valve
32
Mechanical heart valve bridging with surgeries
-No interruption in therapy needed for minor procedure (dental, cataract) -Interrupt w/o bridge in invasive procedure w/ mechanical aortic valve & no risk for TE -Interrupt w/ bridge if invasive procedure w/ mechanical aortic valve w/ risk factor or mechanical mitral valve
33
Caprini Scale
Scale for non-ortho, abdominal pelvic surgery VTE ppx need Risk of >=3 = pharmacologic vte ppx if avg bleed risk Risk >= 5 = pharmacologic and mechanical VTE ppx
34
Anticoagulants for general surgery vte ppx
LMWH > LDUH If unavailable, aspirin 160mg or fondaparinux
35
Bariatric surgery VTE ppx dosing
Higher than all others LDUH: 5000unit SC q8h Enoxaparin: 40mg q12h Dalteparin: 7500 units SC q24h Fondaparinux: 5mg SC q24h
36
PADUA Prediction Score Factors
Active cancer (3) Previous VTE (3) Reduced mobility (3) Known thromboembolic condition (3) Recent (<1mo) trauma/surgery (2) >= 70 y/o (1) Cardiac/respiratory failure (1) Acute MI or ischemic stroke (1) Acute infection and/or rheumo disorder (1) BMI >= 30 (1) Active hormonal treatment (1)
37
PADUA >= 4
Low bleed risk: VTE ppx with LDUH, LMWH, fondaparinux (alt: low-dose rivaroxaban) High bleed risk: mechanical ppx
38
Extended prophylaxis after hospitalization
Rivaroxaban 10mg daily for 35 days, including time in hospital if >=75, prolonged immobilization, cancer hx, VTE hx, HF, thrombophilia, active infectious disease, BMI >=35 *enoxaparin had higher bleed events
39
VTE ppx in pregnancy
LMWH or LDUH Warfarin = teratogenic in first trimester DOACs = no role
40
VTE ppx in obesity
BMI >40 or >120kg reasonable to use: Enoxaparin 40mg BID Enoxaparin 0.5mg/kg BID Dalteparin 7500 units daily Fondaparinux 5mg daily LDUH 7500 q8h
41
VTE ppx duration postop for GI/GU/gyno cancer
up to 28 days
42
VTE ppx duration in general surgery & pts with prior VTE
Duration of hospital stay if no prior VTE up to 28 days if prior VTE
43
VTE ppx duration in patients with major trauma
Up to 8 weeks if impaired immobility in rehab. Otherwise, duration of hospital stay
44
VTE ppx duration in spinal cord injury
Incomplete injury: hospital discharge Uncomplicated complete motor injury: 8 weeks Rehab if complete motor injury: 12 weeks or until discharge
45
Homan sign
Pain in back of knee with dorsiflexon of foot -- sign of DVT
46
Wells Model for DVT Scores
0 = low risk (3%) 1-2 = moderate risk (17%) >=3 = high risk
47
Massive PE
Hemodynamic instability SBP < 90 Cardiogenic shock
48
Submassive PE
Normal SBP Right ventricular dysfunction Positive biomarkers
49
Nonmassive PE
Hemodynamically stable
50
Wells Model for PE Scores
0-1 = low risk (3-10%) 2-6 = moderate risk (15-35%) >= 7 = high risk
51
Dabigatran and Edoxaban bridge therapy for VTE
Injectable anticoagulant for 5 days, then switch to dabigatran or edoxaban
52
UFH dosing VTE
-80 units/kg bolus (max 10,000 units), then 18 units/kg/hr (max 2,000 units/hr)
53
Dalteparin dosing VTE
100 units/kg q12H or 200 units/kg q24h CrCl <30 ml/min = contraindicated
54
Fondaparinux dosing VTE
<50kg: 5mg q24H 50-100kg: 7.5mg q24H >100kg: 10mg q24H CrCl <30 ml/min = contraindicated
55
Apixaban and Rivaroxaban dose reduction after 6 months of VTE therapy
Can go to apixaban 2.5mg BID or rivaroxaban 10mg for extended-phase treatment
56
Provoked VTE duration of therapy
3 months
57
First episode of Provoked VTE by persistent risk factor
At least 3 months, then reassess for extended-phase - If low risk of bleeding and adherent, then low-dose apixaban/rivaroxaban preferred
58
First episode of VTE with thrombophilia (inherited or acquired) duration
At least 3 months, then reassess for extended-phase Low risk of bleed = continue
59
First episode of cancer-related VTE duration
At least 3-6 months, extended if active cancer LMWH preferred over DOAC if GI cancer
60
Second provoked/unprovoked VTE duration
Indefinite
61
Provoked VTE risk factors
Surgery Hospitalization Plaster cast immobilization within 3 months Estrogen Pregnancy Prolonged travel >8 hours Lesser leg injuries Immobilization within 6 weeks
62
Fresh Frozen Plasma dose for warfarin reversal
15-20 mL/kg (around 1.2-1.6L) Critically ill: 30 mL/kg
63
3-factor Clotting factors
II IX X
64
4-factor Clotting factors
II VII IX X
65
Activated PCC factors
II VIIa IX X
66
Cryoprecipitate
Thaw 1 unit of FFP in cold conditions Factor VII, XIII, von Willebrand factor, fibronectin, fibrinogen 0.2 units x kg = 1 g/dL increase in fibrinogen
67
Recombinant activated factor VII
Reversal for UFH, LMWH, DOAC 90 mcg/kg 18-30 mcg/kg documented as ok and cheaper
68
Protamine for UFH
Reversal for UFH 1mg protamine neutralizes ~100 units heparin received in past 2 1/2 hours Max dose 50mg
69
Packed RBCs
1 unit = Hgb increase 1-2 g/dL
70
Platelets
1 unit = 300,000-600,000 platelets
71
Protamine for LMWH
Reverses ~50-60% 1mg protamine neutralizes 1mg of enoxaparin If LMWH administered <8 hours before, then give standard dose If LMWH administered >8 hours before need for reversal, give 0.5mg protamine for every 1mg enoxaparin
72
Vitamin K
Warfarin reversal Delayed onset PO takes 24-48 hours IV (as slow infusion) takes 8-12 hours Avoid SC/IM
73
4PCC dosing for warfarin
ABW INR 2-4: 25 units/kg (max 2500) INR 4-6: 35 units/kg (max 3500) INR >6: 50 units/kg (max 5000) INR <2 with cerebral bleed: 12.5-25 units/kg
74
aPCC dosing for DOAC
25-50 units/kg
75
Dabigatran preprocedural hold time
Low/mod bleed risk surgery CrCl >= 50 = 1 day CrCl <50 = 2 days High bleed risk surgery CrCl >= 50 = 2 days CrCl <50 = 4 days
76
DOAC preprocedural hold time
Low/mod bleed risk surgery = 1 day High bleed risk surgery = 2 days
77
Idarucizumab
Antidote for DTI (dabigatran) 5g IV
78
Andexanet alfa
Coagulation factor Xa (recombinant), inactivated Antidote for factor Xa inhibitors
79
Low dose andexanet alfa
400mg IVB followed by 4mg/min for 2 hours Use if last dose of apixaban 5mg or less or rivaroxaban 10mg or less administered less than 8 hours earlier or unknown
80
High dose andexanet alfa
800mg IVB followed by 8mg/min for 2 hours Use if last dose of apixaban >5mg or rivaroxaban >10mg taken less than 8 hours before or unknown

BCPS (40 decks)

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