dose

Question 1

DVT UFH doses

Answer 1

80 units/kg –> 18units/kg/hr infusion

Question 2

DVT LMWH dose

Answer 2

enoxaparin 1mg/kg Q12H or 1.5mg/kg OD

• enoxaparin renal <30ml/min = 1mg/kg OD

Question 3

DVT riva dose

Answer 3

15mg BD 3wks —> 20mg OD 6mnths —> 10mg OM (prophy)

Question 4

DVT apix dose

Answer 4

10mg BD 7d —> 5mg BD 6mnths —> 2.5mg BD (prophy)

Question 5

DVT rTPA dose

Answer 5

100mg over 2h or 0.6mg/kg over 15mins (max 50mg)

Question 6

DVT UFH prophylaxis

Answer 6

5000units Q8-12h

[medically ill, non-ortho, ortho -TKR, THR 10-14d~35d]

Question 7

DVT enoxaparin prophylaxis

Answer 7

40mg OD until ambulatory

or 30mg BD - surg TKR,THR 10-14d ~ 35d

Question 8

DVT dabigatran prophylaxis

Answer 8

Haemostasis achieved

1-4h post surg 220mg/day (10d TKR)
(28-35d THR)

Question 9

DVT renal dabi

Answer 9

Crcl 30-50ml/min (caution) 150mg OM same duration as above

Crcl <50ml/min + PGPi (avoid)

Question 10

DVT riva prophy

Answer 10

10mg OD

TKR: 2wk
THR: 5wk
medically ill for 31-39d

Question 11

DVT apix prophy

Answer 11

Haemostasis achieved, 12-24h post surg

2.5mg BD (10-14d TKR)
(32-35 days THR)

Question 12

DVT riva renal

Answer 12

Crcl < 30ml/min (avoid)

Question 13

DVT apix renal

Answer 13

Crcl 15-29ml/min (caution)

HD (avoid)

Question 14

DVT edoxaban renal

Answer 14

30mg/day
* Crcl 30-50ml/min
* or BW <60kg

If renal function >95ml/min (too good, tx failure)

Question 15

DVT LMWH renal

Answer 15

Severe renal (crcl <30ml/min): 1mg/kg OD

• same for cancer, preg

prophy:
* Mod renal (30-50ml/min): 30mg BD
Consider anti-Fxa levels

• Severe renal = 20-30mg OD

Question 16

AF dabig dose

Answer 16

150mg BD.
- 110mg BD (if =/>80yo/ use PGPi/ high risk of bleed)
- no crcl dose adj unless CI <30ml/min

Question 17

AF riva dose

Answer 17

20mg OD
- crcl 30-50ml/min = 15mg OD
- crlc <15 ml/min = CI

Question 18

AF apix dose

Answer 18

5mg BD
- 2.5 mg BD (if any 2: Age =/> 80yo, Weight =/<60kg, Scr =/> 1.5mg/dL/ 132.6mmol/L)

crcl 15-29: 2.5mg BD
crcl <15ml, HD is approved by no dose???

Question 19

AF edoxaban dose

Answer 19

60mg OD
- 30mg OD (any: crcl 30-50/ weight =/>50kg, concomitant: werapamil, quinidine, dronedaron)

Crcl <15ml/min = not recomm

Question 20

AMI PCI UFH

Answer 20

2000-5000 units (no more than 50-70 units/kg) to achieve ACT of 250 – 300 seconds;

repeat bolus (max 10 000 units) as needed to maintain ACT throughout PCI.

Question 21

AMI PCI LMWH

Answer 21

If < 75yo, bolus IV 30mg followed by SQ 1mg/kg Q12H

if ≥75yo, omit bolus, followed by SQ 0.75mg/kg Q12H

duration of 48h and up to 8d or until revascularisation.

Question 22

AMI SAPT

Answer 22

Load 300mg (no load if currently on aspirin)
f/b: 100mg OM (lifelong)

Question 23

DAPT clopidogrel doses

Answer 23

clopidogrel (CCS) Load 300mg (6h onset) or 600mg (2h onset)
f/b: 75mg OM

extended therapy (beyond 12mnth): 75mg OD

Question 24

DAPT ticagrelor dose

Answer 24

Load: 180mg
f/b : 90mg BD ~ 12mn
extended therapy (beyond 12mnth): 60mg BD —non MAF

Question 25

DAPT eptifibatide dose

Answer 25

Double bolus of 180ug/kg iv (10min interval) Follow: infusion 2.0ug/kg/min for 72h short t1/2, need infusion.

Question 26

fibrinolytics AIS

Answer 26

within 3hr/ 4.5hr 0.9mg/kg (max 90mg)

Question 27

stroke VTE prophylaixs

Answer 27

LMWH within 48h. after 24h of rTPA - due to immobile state - monitor bleedign risk within 72hr 40mg OD until ambulatory

Question 28

when and how long is DAPT administered in AIS

Answer 28

within 24h - 48h (if given rTPA) ASAP if not rTPA eligible (90d: major ICAS, non-cardioembolic) (21d: minor stroke, high risk TIA)

Question 29

high intensity statins

Answer 29

atorvastatin 40-80mg rosuvastatin 20-40mg add in ezetimbe if LDL > 1.8mmol/L

Question 30

HBP control

Answer 30

ACEi CCB thiazide diuretic

Question 31

management of pernicious anemia/ vit 12 deficiency anemia

Answer 31

* IM, SC vit B12 1000ug daily for 1 wk * Follow: 1000 ug weekly x 4wks * Follow: 1000ug mnthly for life PO often insufficient * PO Vit B12, 1000ug ~ 2000ug daily Absorbed by mass action, not rely on intrinsic factor action *or when IF not that low

Question 32

folate deficiency tx

Answer 32

1mg/d folate for 1-4mnths Or Until hematologic recovery, normal Hb Multivitamin (sangobion, ferrous gluconate)

Question 33

tx for Fe deficiency

Answer 33

Sufficient Fe = 1000 - 1500mg of elemental Fe for complete supplementation Ferrous gluconate tab 30mg sangobion (12%) Iron polymaltose 100mg Maltofer (100%) (20-30 ~~ 200mg). 3-6 mnths to replenish

Question 34

management of aplastic anemia

Answer 34

1) Withdraw causative drug 2) improve peripheral blood counts Transfusion of erythrocytes and PLT * Granulocyte-macrophage CSF: sargramostim, * G-CSF: filgrastim, pegfilgrastim * IL-14 3) minimise risk for infections * Ab prophylaxis, antifungal * Neutrophil count <500 cells/mm3 4) Haematopoietic stem cell transplant (HSCT) 5) Immunosuppressants while bone marrow recovers * Glucocorticoids * Ciclosporin * Cyclophosphamide * Azathioprine * Antithymocyte Ig

Question 35

do not heavily transfuse

Answer 35

iron overload require Fe chelation - Defoxamine - Deferasirox

Question 36

tx for HIT

Answer 36

1) Hold offending drug Recover in 1-2 days. Complete in 1wk Ab may persist for years, do not restart. avoid indefinitely 2) KIV corticosteroid if severe 3) Heparin-induced thrombocytopenia *DOAC: dabigatran (off-label)

Question 37

tx for immune thrombocytopenia

Answer 37

1) Withdraw causative drug 2) Immunosuppressants (KIV) - Glucocorticoids - Ciclosporin - Cyclophosphamide - Azathioprine - Antithymocyte Ig 3) Transfusion of PLT Clinically sig bleeding

Question 38

agranulocytosis tx

Answer 38

1) Withdraw causative drug - blood count usually returns to norm in 2-4wks (~4-24days) 2) Prophylactic administration of hematopoietic GF * GM -CSF: sargramostim ○ More potent, more ADR as it stimulates diff type of blood cells * G-CSF: filgrastim (sc 300mcg/day), pegfilgrastim * Weekly monitor WBC count * Esp for pt with clozapine

Question 39

tx for hemolytic anemia

Answer 39

1) Withdraw causative drug * RBC transfusion for pt with low Hb * Haemodialysis in acute RF * Steroids, Ig in serious cases * Autoimmune hemolytic anaemia Rituximab (human anti-C20 Mab) used

Question 40

drugs that cause megaloblastic anemia + tx

Answer 40

* Antimetabolite = Hold off drug ○ MTX, chemotherapy * Co-trimoxazole = Folinic acid 5-10mg QDS ○ Esp in folate/ vit B12 deficient * Phenytoin, phenobarbital = Switch drug/ folic acid ○ Inhibit folate absorption or catalyse folate catabolism § Folic acid 1mg/day but may decr phenytoin efficacy

Question 41

drugs to tx anemia (nutrient, erythropoeisis)

Answer 41

* Nutrients ○ Vit B12, folate deficiency ○ Fe deficiency * Erythropoiesis-stimulating agents ○ darbepoetin alfa, epoetin alfa

Question 42

tx for leukemia, myelodysplastic syndromes & lymphoma

Answer 42

○ Corticosterois, immunosuppressants, cytotoxic (chemo), targeted synthetic drugs, biologics ○ Supportive therapies for cytopenia - anemia, neutropenia, thrombocytopenia

Question 43

neutropenia drugs

Answer 43

Myeloid GF * granulocyte colony sitmulating factor (G-CSF) ○ recombinant human GCSF -- filgrastim ○ Filgrastin covalently conjugated with PEG -- pegfilgrastin * GM-CSG (macrophage) ○ recombinant human GCSF -- sargramostim

Question 44

thrombocytopenia tx drugs

Answer 44

Megakaryocyte GF/ plt-stimulating agents * Recombinant IL-11: oprelvekin * Fc-fusion protein thrombopoietin receptor agonist (romiplostim) * PO nonpeptide thrombopoietin receptor agonist (eltrombopag)