Anticoagulation

Question 1

Which anticoagulants can be used in the setting of HIT?

Answer 1

Argatobran/Bivalirudin (direct thrombin inhibitors IV)

Question 2

Signs of Heparin-induced thrombocytopenia → sudden drop in _____ by > ___ %)

confirm with serology and antibodies & list on patient’s allergy list!!!

Answer 2

Signs of Heparin-induced thrombocytopenia → sudden drop in platelets by > 50%

confirm with serology and antibodies &
list on patient’s allergy list!!!

Question 3

CHADS-VASc:
risk stratification scale to determine patient’s risk of developing _____ and/or ____

> /=2 is moderate to high risk patient → start ______ for these patients

Answer 3

CHADS-VASc:
risk stratification scale to determine patient’s risk of developing embolism and/or stoke

> /=2 is moderate to high risk patient → start anticoagulation for these patients

Question 4

HAS-BLED:
Bleeding risk scale; scored from 0 to 5 (__ is the highest → >/ = ___% annual bleeding risk)

Disadvantage: does not take into consideration _____

Answer 4

HAS-BLED:
Bleeding risk scale; scored from 0 to 5 (5 is the highest → >/ = 10% annual bleeding risk)

Disadvantage: does not take into consideration falls

Question 5

Answer 5

Question 6

Answer 6

Question 7

Answer 7

Question 8

Answer 8

Question 9

Answer 9

Question 10

Length of VTE therapy:

Long-term therapy = _ months (most common)

Extended therapy = > _ months (weigh bleeding risk vs benefit) only for pts w/ ____ bleeding risk

Answer 10

Length of VTE therapy:

Long-term therapy = 3 months (most common)

Extended therapy = > 3 months (weigh bleeding risk vs benefit) only for pts w/ low bleeding risk

Question 11

Duration of VTE therapy:

Consider:
_____ risk stratification (___-____score) and risk factors

Answer 11

Duration of VTE therapy:

Consider:
bleeding risk stratification (HAS-BLED score) and risk factors

Question 12

Provoked VTE: no ______ event

Unprovoked status: precipitated by surgery, pregnancy, estrogen therapy, reduced mobility > ___ days, hospital admission

Answer 12

Provoked VTE: no identifiable event

Unprovoked status: surgery, pregnancy, estrogen therapy, reduced mobility >3 days, hospital admission

Question 13

Non-cancer vs cancer patient: DOAC > VKA (warfarin) > LMWH (no cancer); LMWH > VKA (warfarin) > DOAC (cancer pt)

Question 14

provoked VTE therapy duration:

Answer 14

long-term: 3 months

Question 15

unprovoked VTE therapy depends on _____ risk

Answer 15

depends on bleeding risk:

1. Low/moderate bleeding risk = extended therapy > 3 months
2. High bleeding risk = 3 months

Question 16

Warfarin dose

___ mg PO x2 days then __ mg PO daily

Elderly/frail: ___-___mg PO daily

Answer 16

Warfarin dose

10 mg PO x2 days then 5 mg PO daily

Elderly/frail: 2.5-5mg PO daily

Question 17

Warfarin is most beneficial for which patients?

Answer 17

noncompliant pts

Mechanical heart valves

CAD

Question 18

Warfarin MOA:

Inhibits factors ___, ___, ___, ___ (contact activation pathway best for _______ heart valves)

Answer 18

Inhibits factors II, VII, IX, X (contact activation pathway best for mechanical heart valves)

Question 19

Cons of Warfarin:

Various interactions w/ food + meds (d/t polymorphisms CYP2C9 & VKORC1)

Answer 19

Cons of Warfarin:

Various interactions w/ food + meds (d/t polymorphisms CYP2C9 & VKORC1)

Question 20

Factors that increase/decrease warfarin (3)

Answer 20

Dietary vitamin K increase –> decrease warfarin

Alcohol increase –> increase warfarin

Smoking increase
–> decrease warfarin

Question 21

Side effects of warfarin (3):

Answer 21

Side effects of warfarin (3):

1. bleeding
2. skin necrosis
3. purple toe syndrome

Question 22

Warfarin INR Goals:

VTE + afib: ___ to ___

Mechanical heart valve: ____ to ___

Answer 22

Warfarin INR Goals:

VTE + afib: 2-3

Mechanical heart valve: 2.5-3.5

Question 23

Warfarin reversal

Answer 23

Vitamin K

Question 24

Warfarin requires or does not require bridging with Lovenox?

Answer 24

Bridging with Lovenox required for a min. of 5 days in VTE indication b/c full therapeutic effects seen 5-7 days of initiation or dose changes

Question 25

most commonly used DOACs:

Answer 25

1. Apixaban (Eliquis) 2. Rivaroxaban (Xarelto):

Question 26

Apixaban (Eliquis) Dosing: Stroke prophylaxis: ___ mg PO BID Tx of DVT/PE: ____ mg PO BID x 7 days, then ___ mg PO BID

Answer 26

Apixaban (Eliquis) Dosing: Stroke prophylaxis: 5 mg PO BID Tx of DVT/PE: 10 mg PO BID x 7 days, then 5 mg PO BID

Question 27

Rivaroxaban (Xarelto) Dosing: Stroke prophylaxis: CrCl > 50mL/min ____ mg PO daily w. Evening meal Tx of DVT/PE: ___ mg PO BID x ___ days, then ___ mg PO daily; CrCl < 30mL/min avoid use

Answer 27

Rivaroxaban (Xarelto) Dosing: Stroke prophylaxis: CrCl > 50mL/min 20 mg PO daily w. Evening meal Tx of DVT/PE: 15 mg PO BID x 21 days, then 20 mg PO daily; CrCl < 30mL/min avoid use

Question 28

WHICH ANTICOAGULANT AM I? Dose: renally adjusted + has an induction period for tx of DVT/VTE (high recurrence) Falsely elevates aPTT and INR → not a red flag just a s/e ANTIDOTE: Andexxa very expensive Premature discontinuation increase risk of thrombotic events

Answer 28

DOACs

Question 29

Why is Edoxaban not used often? Betrixaban?

Answer 29

Edoxaban: Small CrCl window so not used much Betrixaban: expensive + long duration 35-42 days

Question 30

Do DOACs require frequent monitoring for efficacy? What should you monitor in DOACs?

Answer 30

No frequent monitoring (patient prefer these) Monitor: Hgb, Hct, SCr, LFTs q 3-6mos.

Question 31

Which patients benefit from DOACs?

Answer 31

Active GI bleed, no bridging, renal dz, CAD: use Apixaban Noncompliant pt: Rivaroxaban (once daily dosing)

Question 32

When should DOACs not be used? Not recommended w/ _____ ______ _____ Avoid in pts w/ severe _____ impairment Warning: pt receiving ______ anesthesia (epidural, spinal) or ______ puncture → risk of _____ ______ , ______

Answer 32

Not recommended w/ prosthetic heart valves Avoid in pts w/ severe hepatic impairment Warning: pt receiving neuraxial anesthesia (epidural, spinal) or spinal puncture → risk of hematomas bleeding , anemia

Question 33

ORAL Direct Thrombin Inhibitor:

Answer 33

Dabigatran (Pradax)

Question 34

Dabigatran (Pradax) Dose: Stroke prophylaxis: ___ mg BID or ___ mg BID for CrCL 15-30mL/min Tx of DVT/PE: ___ mg BID after 5-10 days of parenteral anticoagulation

Answer 34

Dabigatran (Pradax) Dose: Stroke prophylaxis: 150 mg BID or 75 mg BID for CrCL 15-30mL/min Tx of DVT/PE: 150 mg BID after 5-10 days of parenteral anticoagulation

Question 35

Does Dabigatran (Direct thrombin inhibitor) require frequent monitoring for efficacy?

Answer 35

No frequent monitoring

Question 36

Which oral anticoagulant has the highest risk GI bleeding?

Answer 36

Dabigatran (Pradax)

Question 37

Who should Dabigatran avoided in? Avoid in active _____, pts w/ _____ _____ _____ Warning: Pts receiving _____ anesthesia (epidural/spinal) or _____ puncture → increased risk of _______;

Answer 37

Avoid in active bleeding, pts w/ mechanical prosthetic heart valves Warning: Pts receiving neuraxial anesthesia (epidural/spinal) or spinal puncture → increased risk of hematoma;

Question 38

Side effects of Dabigatran: (3)

Answer 38

Side effects of Dabigatran: 1. Dyspepsia 2. gastritis-like symptoms 3. bleeding (GI)

Question 39

What should you monitor in patient receiving dabigatran?

Answer 39

Monitor: Hgb, Hct, Scr

Question 40

A patient has elevated aPTT, PT/INR while on Dabigatran, what is your concern?

Answer 40

Dabigatran can falsely increase aPTT, PT/INR. This is not a red flag.

Question 41

Dabigatran antidote

Answer 41

Antidote: idarucizumab (Praxbind)

Question 42

How should Dabigatran be stored? Protect from _____; dispense in _____ container + discard after __ mos of opening.

Answer 42

Protect from moisture; dispense in original container + discard after 4 mos of opening.

Question 43

WHICH ANTICOAGULANT? Active GI bleed, no bridging, renal dz, CAD: use Apixaban

Answer 43

Apixaban

Question 44

WHICH ANTICOAGULANT? Noncompliant pt:

Answer 44

Rivaroxaban (once daily dosing) or warfarin

Question 45

Pt has an elevated aPTT and INR on DOACs (apixaban/rivaroxaban) what is your concern?

Answer 45

Falsely elevates aPTT and INR → not a red flag just a s/e

Question 46

Antidote for Apixaban/rivaroxaban?

Answer 46

ANTIDOTE: Andexxa very expensive

Question 47

why shouldn't DOACs be prematurely discontinued?

Answer 47

increase risk of thrombotic events

Question 48

Answer 48

Question 49

Answer 49

Question 50

Cancer, Liver disease, coagulopathy, pregnancy: ____ Avoid Bridging/Parenteral: _______ Low compliance (once daily dosing): _____, ____ (has long half-life), ______ (downside: has low CrCl window) Renal disease+CAD: _____, _____ GI bleed: ______ Thrombolytic therapy use: IV ____ CAD: ______, _____

Answer 50

Cancer, Liver disease, coagulopathy, pregnancy: LMWH Avoid Bridging/Parenteral: DOACs (rivaroxaban or apixaban) Low compliance (once daily dosing): rivaroxaban, warfarin (has long half-life), edoxaban (downside: has low CrCl window) Renal disease + CAD: warfarin, apixaban GI bleed: apixaban Thrombolytic therapy use: IV heparin