Anticoagulation

Question 1

Heparin

MOA

Prophy

Txt of VTE and ACS

Antidote

SE

Monitoring

Answer 1

MOA: binds to AT then inactivates thrombin factor 2a and 10a. prevent fibrin conversion.

Prophy: 5k sc q8-12

Txt VTE: 80u/kg bolus then 18 u/kg infusiob

TxtACS: 60u/kg bolus then 12u/kg infusion

Antidote: Protamine (1mg will reverse 100u. max 50mg)

SE: Bleeding, Thrombocytopenia, HIT, Hyper K, osteoporosis (long term)

Monitor: aPTT q 6 hrs (1.5x - 2 control) or anti-Xa, Plt, Hgb, Hct

Question 2

Enoxaparin

Brand

BBW

MOA

Prophy

Txt of VTE

SE:

Monitor

Answer 2

Brand: Lovenox

Boxed warnings: spinal puncture; risk of hematomas and paralysis

MOA: binding to AT and have a greater affinity to Xa than 2a

Prophy: 30mg sc q 12h or 40mg qd (Crcl less than 30: 30mg SC qd)

Txt of VTE: 1mg/kg sc q 12 or 1.5mg/kg sc qd (CrCl less than 30: 1mg/kg sc qd)

SE: bleeding, thrombocytopenia, HyperK, Increase LFTs

Monitor: Scr Anti-Xa (in pregnancy)

Antidote: Protamine
DO NOT EXPEL THE AIR BUBBLES

Question 3

Deltaparin

Brand?
MOA

Answer 3

Fragmin

MOA: binding to AT and have a greater affinity to Xa than 2a

Question 4

HIT

Answer 4

Can lead to a prothrombotic state.

Dx: unexplained drop in PLT (50% from baseline)

Stop all forms of heparins; stop warfarin and start vit K)

Start argatroban

Question 5

Apixaban

Brand, BBW, MOA, Afib, Txt of DVT/PE, warning

Answer 5

B: Eliquis

BBW: risk of hematomas and paralysis with spinal puncture (ALL direct Xa inhibitors); risk of thrombotic events with premature d/c

Warning: not recommended in prosthetic heart valve. (Use warfarin)

MOA: Direct Xa inhibitor

Afib: 5mg BID; Unless pt is 2 of 3: over 80, under 60kg, or SCr 1.5 then 2.5 BID

Txt of DVT/PE: 10mg BID x 7d then 5mg BID

Question 6

Betrixaban

Brand, indication, warning

Answer 6

Brand: Bevyxxa

Warning: not recommended in prosthetic heart valve. (Use warfarin)

indicated for prophylaxis of DVT prophy in hospital and extended care

Question 7

Edoxaban

Brand, warning, Afib dosing

Answer 7

Brand: Savaysa

BBW: reduce efficacy in CrCl greater than 95 ml/min

Warning: not recommended in prosthetic heart valve. (Use warfarin)

AAfib: CrCl over 95; do not use
51-95: 60mg qd
15-50: 30mg qd
less than 15 do not use

Question 8

Rivaroxaban

Brand, Afib, DVT, Missed dose, DI

Answer 8

Xarelto, Xarelto Starter pack (use for DVT txt)

doses above = to or above 15 take with food

Afib: CrCl> 50ml/min; 20mg qd WITH FOOD
15-50: 15mg qd WITH FOOD

Txt of DVT/PE: 15mg po BID x 21 days then 20mg qd.

BID Missed dose: if taking 15mg BID then ta)ke both as soon as you remember then resume.

DI: A major 3A4 substrate and p-gp

Question 9

Fondaparinux

Brand; Contraindication

Answer 9

Arixtra

CrCl less than 30: do not use

Question 10

Conversion between AntiCoag

Answer 10

going from warfarin to another Anticoag:

R: Rivaroxaban when INR is less than 3
E: Edoxaban when INR is less than 2.5
A: Apixaban when INR is less than 2
D: Dabigatran when INR is less than 2

Question 11

Dabigatran

brand, afib, se, antidote, counseling point

Answer 11

Pradaxa
MOA: Direct 2a inhibitor

afib: 150mg BID
15-30 crcl: 75mg bid
less than 15 do not use.

SE: gastritis-like symptoms

Antidote: Praxabid (Idarucizumab)

CP: Take with full glass of water! KEEP IN OG CONTAINER IF dose is less than 6 h skip

Question 12

Argatroban

Indication, MOA

Answer 12

Indication: HIT or PCI at risk for HIT

MOA: Direct thrombin inhibitor

Question 13

Bivalirudin

Brand, indication MOA

Answer 13

Angiomax

Indication: ACS undergoing PCI (preferred if undergoing cardiac surgery)

Question 14

Desirudin

Brand, Indication

Answer 14

Iprivask

VTE prevention after hip arthrolplasty

Question 15

Warfarin

Brand, MOA, active enatiomer, SE

Answer 15

Coumadin, Jantoven

MOA: competitively inhibit VKORC1 to decrease SNOT and protein C&S

S-enatiomer more potent

SE: skin tecrosis, Purple toe syndrome
Highly protein bound 99%

Question 16

Warfarin

Dosing, Warnings, Goal Antidote

Answer 16

Healthy pt: 10mg qd x 2 days then adjust

start 5mg or less in: Elderyl, 3a4 inhibitors, liver disease, HF, malnorished.

warnings: HIT (contraindicated as monotherapy in HIT) Presence of 2C92/3 or polymorphism of VKORC1

INR: 2-3 ;2.5-3.5 for mechanical mitral valve or 2 mechanical heart valve

antidote vit k

Question 17

Warfarin color

Answer 17

Pink 1mg
Lavender 2mg
Green 2.5mg
Brown 3mg
Blue 4mg
peach 5mg
Teal 6mg
yellow 7.5 mg
white 10mg

Question 18

5 G’s that increases bleeding risk

Answer 18

Garlic, Ginseng, ginko, ginseng, glucosamine

Question 19

Warfarin use in DVT

Answer 19

Begin warfarin with parenteral anticoag for a min of 5 days AND until INR is greater than 2 for at least 24 hours

Question 20

Protamine

Answer 20

1mg will reverse 100u of heparin

Question 21

Idarucizumab

brand, use

Answer 21

Praxabind

pradaxa antidote

Question 22

Vitamine K/Phytonadione

Brand, SE, SC, IM

Answer 22

Mephyton
SE: Anaphylaxis
SC route not recommended due to variable absorption
IM route causes hematoma

Question 23

Four Factor Prothrombin Complex Concentrate

Brand, Factors, coadmin with?

Answer 23

kCENTRA
Has factors SNOT and protein C&S

Admin Vit K at the same time

Question 24

Factor 7a recombinant

Answer 24

NovoSeven RT

Question 25

Vit K use

Answer 25

INR above 4.5 reduce or skip warfarin dose 4.5-10 w/o bleeding: Hold 1 - 2 doses of warfarin 10 w/o bleeding: Hold warfarin. Give ORAL vit K 2.5 - 5mg Major bleeding from warfarin: Hold warfarin.. Give Vit K 5 - 10mg by SLOW IV and Kcentra

Question 26

bridging therapy

Answer 26

means stop warfarin therapy and using LMWH or UFH for short period to prevent clotting

Question 27

VTE Risk factors

Answer 27

Surgery, Immobility, Cancer/chemotherapy, pregnacy, ESA, Estrogen, hx of VTE, major trauma.

Question 28

Long Distant travel prophy

Answer 28

Use exercise. not aspirin or anticoag

Question 29

VTE Txt

Answer 29

Should be treated for 3 months W/o cancer: R.E.A.D are preferred over warfarin for DVT or PE W/ Cancer: LWMH are preferred over all anticoags (including warfarin) Aspirin is recommended for 2nd prophy is VTE was unprovoked

Question 30

CHADS2

Answer 30

``` CHF = 1 , HTN = 1, Age >75 = 1, Diabetes = 1 S = stroke or TIA = 2 ``` score of: 0 = no therapy 1 = oral anticoagulation rather than anti platelets 2 or more: oral anticoags indefinitely.

Question 31

CHA2DS2VASc

Answer 31

Age 75 yo or older = 2, Vascular disease (prior MI. PAD, aortic plaque) = 1, Age = 65 - 74 years Sex Category female = 1 Score of: 0 = No anticoag 1 = ASA may be cosidered 2 or more = Oral coag is recommended. (R.E.A.D)