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DOACs and Warfarin Flashcards

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1
Q

name the DOACs

A

rivaroxaban, edoxaban, apixaban, dabigatran

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2
Q

rivaroxiban brand name

A

xarelto

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3
Q

apixaban brand name

A

eliquis

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4
Q

edoxaban brand name

A

savaysa

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5
Q

dabigatran brand name

A

pradaxa

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6
Q

dabigatran indications

A

NVAF, VTE prophylaxis (orthopedic surgery), treatment of VTE & risk of reduction of recurrence

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7
Q

rivaroxaban indications

A

NVAF, VTE prophylaxis, treatment of VTE, reduction in risk of recurrence of DVT/PE in pts @ continued risk, reduction in risk of major CV events (death, MI, stroke) in chronic CAD or PAD

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8
Q

apixaban indications

A

NVAF, VTE prophylaxis (orthopedic surgery), treatment of VTE and reduction in risk of recurrence)

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9
Q

edoxaban indications

A

NVAF, treatment of DVT and PE

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10
Q

what is the apixaban dosing for NVAF

A

5 mg po bid

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11
Q

what is the apixaban dosing for NVAF if pt is older than 80, weighs less than 60 kg, or has serum creatinine greater than 1.5

A

2.5 mg po bid

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12
Q

do DOACs require bridging like warfarin?

A

NO!

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13
Q

overdosing DOACs doubles risk of ____

A

bleeding

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14
Q

underdosing DOACs causes a 5-fold increased risk of _____

A

stroke

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15
Q

which DOACs can we use in patients who weigh more than 120 kg or have BMI over 40 (OBESE)

A

rivaroxaban or apixaban

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16
Q

which anticoagulants have safer profile: DOACs or warfarin

A

DOACs

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17
Q

adverse effects of DOACs

A

bleeding (GI hemorrhage)

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18
Q

adverse effects specific to dabigatran

A

dyspepsia, nausea

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19
Q

contraindications to DOACs

A

active major bleed, advanced CKD (CrCL <15) except apixaban, and CrCL<30 mL/min for VTE prophylaxis/treatment

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20
Q

what types of drug-drug interactions exist for DOACs

A

P-glycoprotein and CYP3A

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21
Q

strong P-gp inhibitors ____ DOAC concentrations

A

increase

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22
Q

what are some strong P-Gp inhibitors

A

ketoconazole, itraconazole, clarithyromycin, dronedarone, amiodarone, verapamil, quinidine, cyclosporine, conivaptan, ritonavir, lopinavir, indinavir

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23
Q

strong P-gp inducers ____ DOAC concentrations

A

decrease

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24
Q

what are some strong p-gp inducers

A

rifampin, carbamazepine, phenytoin, St. John’s wort

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25
Strong CYP3A inhibitors _____ DOAC concentrations
increase
26
what are some strong CYP3A inhibitors
azole antifungals, macrolides, protease inhibitors
27
strong CYP3A inducers _____ DOAC concentrations
decrease
28
what are some strong CYP3A inducers
rifampin, carbamazepine, phenytoin, st. john's wort
29
dabigatran and edoxaban are metabolized by __
P-gp
30
apixaban and rivaroxaban are metabolized by ___
CYP3A and P-gp
31
what are the DOAC trial exclusions in NVAF
mechanical heart valves, hemodynamically significant mitral stenosis, advanced CKD, significant liver disease, recent stroke (7-14 days), pregnancy/lactation, severe HTN, reversible causes of AFib
32
what are the guidelines for pregnancy w/ anticoagulants
no DOACs. warfarin is teratogenic in first 2 trimesters, use enoxaparin. can use warfarin in 3rd trimester
33
reversal agent/antidote for dabigatran
idaracizumab (praxbind)
34
what is the reversal agent FDA approved for apixaban and rivaroxaban
coagulation factor Xa (andexxa)
35
all DOACs are at least ____ to warfarin for reducing risk of stroke/systemic embolism
not inferior
36
which DOACs are superior to warfarin for risk of stroke/ systemic embolism
dabigatran 150 mg and apixaban
37
all DOACs reduce the risk of ____ versus warfarin
major bleeding
38
you should withhold DOACs for ____ prior to procedure depending on bleed risk and kidney function
24-48 hours
39
after initiating warfarin, there is a ______ state
hypercoagulable
40
explain how warfarin causes a hypercoagulable state when first initiated
it also depletes some of your body's own natural anticoagulants like protein c and protein s
41
how do we allow for a slow onset of warfarin since there is a hypercoagulable state?
use a parenteral to bridge for 3-5 days
42
warfarin interferes with _____ dependent clotting factors
vitamin k
43
the protein target of warfarin is ____
VKORC1 (vitamin K oxide reductase 1)
44
VKORC1 is the enzyme responsible for ___
activation of clotting factors that depend on vitamin K as a cofactor
45
VKORC1 oxidizes the reduced form of Vit K, and carboxylates the inactive clotting factors to make them ___
active
46
warfarin is a ___ mixture
racemic (r and s isomers)
47
warfarin is highly bound to ____
albumin (95%)---> drug interactions
48
the r isomer of warfarin is metabolized by ___
CYP3A4
49
the s isomer of warfarin is metabolized by ___
CYP2C9
50
how do you monitor warfarin
INR
51
what drug interactions with warfarin would INCREASE inr (risk for bleed)
alcohol, amiodarone, anabolic steroids, cimetidine, clarithromycin, cotrimoxazole, erythromycin, fluconazole, isoniazid, metronidazole, miconazole, omeprazole, phenylbutazone, piroxicam, propafenone, propranolol, vit. E
52
what drug interactions with warfarin would DECREASE INR (risk for clot)
barbiturates, carbamazepine, chlordiazepoxide, cholestyramine, nafcillin, rifampin, sucralfate, dicloxacillin, azathioprine, cyclosporine, trazodone, vit K
53
is a loading dose necessary for most patients starting warfarin
NO
54
what is the initial dose for warfarin
2-5 mg daily
55
bridge warfarin with ______ for 4-5 days
heparin
56
how do you adjust the dose of warfarin
10-15% of weekly dose
57
adverse effects of warfarin
bleeding, skin necrosis, purple toe
58
indications for warfarin
DVT, PE, prevention of systemic embolism (stroke)---> biprosthetic heart valves short term, acute MI, LV dysfunction, LV thrombus, AFib, mechanical prosthetic valve (mitral), mechanical prosthetic valve (aortic)
59
what is the therapeutic INR range for warfarin
2-3
60
what is the therapeutic INR range for warfarin if indication is mechanical mitral prosthetic valve
2.5-2.5
61
patient counseling points for warfarin
signs of bleed, signs of clot, INR monitoring and dosage, tablet identification, common drug interactions, consistent intake of dietary vitamin k
62
what are the reversal agents for warfarin
vitamin k (phytonadione), fresh frozen plasma, prothrombin complete concentrates like profilnine (3 factor) and kcentra (4 factor), recombinent factor VIIa (novoseven)
63
what is the target of dabigatran
thrombin (factor IIa)
64
what is the target of apixaban
Xa
65
what is the target of rivaroxiban
Xa
66
what is the target of edoxaban
Xa

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