Length of VTE Treatment for Provoked w/ cancer
Forever
Length of VTE Treatment Provoked, Others
3 months
Length of VTE Treatment, Unprovoked, PE
Forever
Length of VTE Treatment, Unprovoked, Recurrent (2nd) DVT
Forever
Length of VTE Treatment, Unprovoked, 1st DVT, DISTAL
3 months
Length of VTE Treatment, Unprovoked, 1st DVT, PROXIMAL
Forever
STROKE/A. FIB.
Dosing and Exceptions for: Dabigatran [Pradaxa]
Counseling points?
Dosing: 150 BID
If CrCl 15-50 mL/min : 75 mg BID
No pill box
May cause dyspepsia/gastritis
STROKE/A. FIB.
Dosing and Exceptions for: Apixaban [Eliquis]
Counseling Points/Notes?
Dose: 5 mg BID
If (2 out of 3) Scr >1.5, Age > 80 yrs, or Wt. < 60 kg: 2.5 mg BID
Best for patients on dialysis, end stage CKD,]/ poor renal function (no dose adjustment required)
STROKE/A. FIB.
Dosing and Exceptions for: Rivaroxaban [Xarelto]
Counseling points?
Dose: 20 mg QD
If CrCl 15-50 mL/min: 15 mg QD
TAKE WITH LARGEST FATTY MEAL
STROKE/A. FIB.
Dosing and Exceptions for: Edoxaban [Savayxa]
Dose: 60 mg QD
If CrCl 30-60 mL/min (Stroke) or 15-50 mL/min (Afib): 30 mg QD
AVOID: in patients with CrCl > 95 mL/min and in patients with <15 mL/min
STROKE/A. FIB.
Dosing and Exceptions for: Betrixaban [Bevyxxa]
Counseling points?
Tricked ya! DO NOT use in stroke/Afib.
Take with food tho…
ACUTE VTE:
Dosing and Exceptions for: Dabigatran [Pradaxa]
Counseling points?
Dose: 5 days parenteral AC, 150 mg PO BID
D/C if CrCl < 30 mL/min
No Pill Box
discard 4 months after opening
ACUTE VTE:
Dosing and Exceptions for: Apixaban [Eliquis]
Counseling points?
Dose: 10 mg PO BID x 7 days, then 5 mg PO BID
D/C if CrCl < 25 mL/min OR Scr > 2.5 mg/dL
ACUTE VTE:
Dosing and Exceptions for: Rivaroxaban [Xarelto]
Counseling points?
Dose: 15 mg PO BID x 21 Days, then 20 mg po ONCE DAILY
D/C if CrCl < 30 mL/min
Take with LARGEST meal of the day
ACUTE VTE:
Dosing and Exceptions for: Edoxaban [Savaysa]
Counseling points?
WEIGHT BASED
Dose: 5 days of parenteral AC then,
If > 60 kg: 60mg QD
If ≤ 60 kg: 30 mg QD
D/C if CrCl < 15 mL/min
ACUTE VTE:
Dosing and Exceptions for: Betrixaban [Bevyxxa]
Counseling points?
Dose: None
Which Drug(s) are only used for: EXTENDED VTE TREATMENT?
Dosing?
Eliquis: 2.5 mg PO BID
Xarelto: 10 mg PO QD
Note: half of maintenance dose
Which Drug(s) are only used for: VTE PROPHYLAXIS?
Dosing?
Dabigatran
Apixaban
Rivaroxaban
Betrixaban [Bevyxxa]: 160 mg PO as single dose on day 1, then 80 mg daily
ALL DOACs EXCEPT Savaysa
Monitoring Parameters for DOACs?
SCr, Renal Function, LFT, Hgb/Hct/Plt
But No Routine for DOACs
Monitoring Parameters for UFH?
aPTT, Scr, Hgb/Hct/Plt
CYP3A4 Inducers
Carbamazepine, Rifampin, St. John’s Wart, Phenytoin
CYP3A4 Inhibitors (VAPED)
Verapamil Amiodarone/Azoles Protease Inhibitors Erythromycins Diltiazem
When do you initiate VTE prophylaxis post-operatively in orthopedic surgery?
What is the drug of choice?
Dose?
12 hours post-operatively
Drug of choice: Enoxaparin [Lovanox]
Dose: 30 mg SC BID
List Direct Thrombin Inhibitors
Bivalirudin [ Angiomax]
Argatroban
List Direct Thrombin Inhibitor(s)
Dabigatran [Pradaxa]
List Vitamin K antagonist(s)
Warfarin [Coumadin, Jantoven]
What clotting factors does Jantoven inhibit?
II, VII, IX, X
+ Protein C and S
Unfractionated Heparin Dosing
Prophylactic Dose?
Treatment Dose?
Prophylaxis Dose: 5000 IU SC BID/TID
TRM Dose: 80 units/kg IV Loading Dose, then 18 units/kg/hr continuous infusion use ABW
Unfractionated Heparin Reversal:
What drug?
What dose?
Protamine: 1 mg/ 100 units
MAX DOSE is 50 mg IV Bolus over 15 minutes
Dosing for Lovenox
prophylaxis dosing?
Treatment dosing?
Prophylaxis Dose: 40 mg SC daily
if CrCl < 30 mL/min: 30 mg SC daily
TRM dose: 1mg/kg SC BID
if CrCl < 30 mL/min: 1mg/kg SC daily
LMWH is eliminated __________
RENALLY!
Monitoring Parameters for Argatroban and Bivalirudin
aPTT
Max dose of Simvastatin with Amlodipine
Simvastatin 20 mg
Max dose of Simvastatin with Amiodarone
Simvastatin 20 mg
Max dose of Lovastatin with Amiodarone
Lovastatin 40 mg
Max dose of Lovastatin with Non-DHP CCBs
Lovastatin 20 mg
Max dose of Simvastatin with Ranolazine
Simvastatin 20 mg
Max dose of Non-DHP CCBs with Simvastatin
Simvastatin 10 mg
Absolute Contraindication with cilostazol
Heart Failure
Contraindication with Prasugrel
TIA/STROKE
HEART FAILURE
Dosing for: Hydralazine/Isosorbide dinitrate [BiDil]
Is it treating symptoms/ morbidity & mortailty / both?
Starting Dose: 37.5/20mg (1 tablet) po TID
Target Dose: 2 tablets po TID
Treats Both
What are the compensatory responses to myocardial damage?
SNS Activation
RAAS Activation
Increase Vasopressin
Right Ventricular Failure
Peripheral Edema
Weight Gain
JVD
Hypervolemic Hyponatremia
Target Digoxin Level in HF
0.5 - 0.9
Target Digoxin Level in A fib
0.8 - <2.0
What are the Major DDIs with Digoxin (4 drugs)
Amiodarone, Dronedarone, Quinidine, and Verapamil
IV Vasodilators
Nitroglycerin, Nesiritide, Nitroprusside
IV Inotropes
Dobutamine, Milrinone, (dopamine)
IV Diuretics
Furosemide, Bumetanide
IV Fluids
0.9% NaCl
Vasopressors
epinephrine, norepinephrine, [dopamine (if SBP <90)]
“Wet” Signs and symptoms of ADHF
Dyspnea, Orthopnea, PERIPHERAL EDEMA, Ascites, JVG, PCWP > 18 mm Hg
“Cold” Signs and symptoms of ADHF
Weakness, Fatigue, Altered mental status, Decreased Urine output, worsening renal function, Cold extremities, Hypotension, CI < 2.2 , SaO2 < 90%
Max dose: IV Furosemide
200 mg
Max dose: IV Bumetanide
5 mg
Nitroprusside dose in ADHF
0.2 mcg/kg/min
ADR for Nitroprusside
Hypotension (BBW)
Cyanide toxicity (BBW)
Thiocyanate Toxicity
Treatment for Nitroprusside Toxicity
sodium thiosulfate
Initial Dosing for Ivabradine (Corlanor) **Exceptions? If HR > 60? HR 50-60? HR < 50 OR symptoms of bradycardia
Initial: 5 mg po BID
2.5 mg BIF conduction defects
HR > 60: increase dose by 2.5 mg
HR 50 - 60: Maintain dose
HR <50: decreased dose by 2.5 mg or D/c if already at 2.5 mg BID
MAX dose for Ivabradine [Corlanor]
7.5 mg po BID
When can you replace Beta Blockers with Ivabradine in HF? Requirements:
pts w/ NSR, EF <35%, and on max beta-blocker therapy/ CI with BB.
Contraindications of Corlanor:
Acute Decompensated HF HR < 60 before starting therapy BP <90/50 3rd degree AV block Pacemaker CYP3A4 inhibitors Hepatic Impairment Atrial Fibrillation
When should serum digoxin concentrations be drawn?
at least 6-8 hours after last dose (optimally 12-24 hours after a dose)
Digoxin Adverse Effects
GI, Visual, Cardiac (bradycardia, AV block, Ventricular Tachyarrythmia)
Factors that increase digoxin toxicity
Electrolyte imbalance: HYPOkalemia, HYPOmagnesimoa
Alkalosis
Digoxin levels great than 2 ng/mL
Antidote for digoxin toxicity:
Digibind
Drugs to Avoid in HF:
NSAIDs Non-DHP (HFrEF) Thiazolidinediones (Pioglitazone) METFORMIN K-supplements Pseudoephedrine Na containing preparations (fleet enemas)
Diagnosis of PAD using ABI is
ABI ≤ 0.9
Absolute Contraindication for Fibrates
Renal Failure
Hepatic Failure
Gallbladder disease
CrCl < 30 mL/min
Main Lipid Lowering effect of Fibrates
Trigs
Main Lipid Lowering effect of Fish Oil
TGs
Caution in Bile Acid Sequestrants in patients with:
Elevated Trig levels (greater than 300)
An adverse effect of BAS
constipation
Rule of thumb for administering Cholestyramine and Colestipol
Administer all other drugs 1 HOUR BEFORE or 4-6 HOURS AFTER BAS
Rule of thumb for administering Colesevelam
Administer at least 4 HOURS BEFORE WELCHOL
Main lipid-lowering effect of BAS
reduces cholesterol
What co morbidities are at highest risk for PAD
HTN, DM, Hyperlipidemia
QRS complex correlates to which phase(s)?
phase 0
QRS complex represents what type of myocyte action potential?
Ventricular Depolarization
Using ________ will slow phase 0 and prolong QRS
Na blockers
QT interval represent which phase(s)?
Start of phase 0 and end of phase 3
Using ________ will lengthen phase 1,2,3 and prolong QT interval
K channel blockers
Class 1 antiarrhythmics MOA
Block Na channels (and K channels if class 1a)
P wave represents what type of myocyte action potential?
Artial Depolarization
T wave represents what type of myocyte potential?
Ventricular Repolarization
Duration of Na blockade for: Class 1a antiarrhythmics:
intermediate on-off
Duration of Na blockade for: Class 1b antiarrhythmics:
fast on-off
Duration of Na blockade for: Class 1c antiarrhythmics:
long on-off
K channel blockers will lengthen which phase(s)?
Phases 1, 2, and 3
ADR for Quinidine
Cinchonism (poisoning due to excessive ingestion of cinchona alkaloids)
Which Class 1a antiarrhythmic(s) have strong anticholinergic effects.
Quinidine and Disopyramide (Norpace)
Which drugs can cause “Drug-Induced Lupus Erythematosus like syndrome”
Procainamide and Hydralazine (Apresoline)
What is the BBW for all Class 1 antiarrhythmics
Structural Heart Disease
Which electrolyte imbalance decreases quinidine efficacy
Hypokalemia
Which Class 1 subclass only works on Ventricular arrhythmias?
Class 1b
MOA of Class 1b drugs
Binds to both OPEN and INACTIVATED Na Channels`
Which Class 1 subclass has high binding affinity to ISCHEMIC TISSUE
Class 1b
ADR for Mexiletine (Mexitil)
Hepatoxicity
Most potent class 1 antiarrhythmics
Class 1c
What do Class 1c drugs do to an ECG
increase QRS
CAST Trial proved what?
Only use Class 1 drugs in STRUCTURALLY NORMAL HEARTS
ADR for Flecainide (Tambocor)
Dizziness, Blurred Vision
ADR Propafenone (Rhythmol)
Dizziness, Blurred Vision, AND Taste Disturbances
Pill the Pocket Drugs
Flecainide or Propafenone (Rhymol)
Define “Pill in the Pocket”
Self-administration of a single dose of class 1c drugs outside of the hospital at the onset of palpitations
Which Drug(s) with the least TdP Risk?
Amiodarone > Dronedarone (Multaq)
Monitoring Parameters for Amiodarone
Chest X-Ray
Pulmonary Function Tests (PFTs)
Liver Function Tests (LFTs)
Thyroid Function Tests (TFTs)
Amiodarone is an inhibitor of:
inducer of:
inhibitor of: p-gly-p, CYP 1A2, 3A4, 2C9, 2D6
Inducer of: CYP 3A4, 2C8
If you give Amiodarone with Digoxin then:
Decrease Digoxin dose by 50%
If you give Amiodarone with Warfarin then:
Decrease Warfarin dose by 30-50%
Contraindications for Multaq
BBW: Symptomatic HF, NYHA IV HF
Permanent AF, HR <50, QTc > 500 ms, Pregancy, Hepatic impairment
Unfractionated Low Molecular Weight Heparin Reversal:
What drug?
What dose?
Protamine: 1 mg/ 1 mg of enoxaparin administered \
MAX DOSE: 50 mg over 15 mins
Which AADs can be used as pre-treatment in order to enhance the success of direct current cardioversion and prevent recurrent AF
Amiodarone [Cordarone] Propafenone [Rhymol] Sotalol [Betapace] ibutilide [ Corvert ] Flecainide [Tambocor]
Which AAD is used for maintenance in rhythm control?
"ADD Some Fries Please" Amiodarone [Cordarone] Dronedarone [Multaq] Dofetilide [ Tikosyn ] Sotalol [ Betapace] Flecanide [ Tambocor ] Propafenone [Rhythmol]
