Emergent Reversal of Anticoagulants

Question 1

reversal for antiplatelet

Answer 1

platelet transfusion

Question 2

reversal for heparin

Answer 2

protamine

Question 3

reversal for vitamin K antagonists

Answer 3

• 3 and 4 factor PCCs

- vitamin K

Question 4

reversal for direct thrombin inhibitors

Answer 4

• idarucizumab

- andexanet alfa

Question 5

FFP

Answer 5

• variable but near normal levels of coagulation factors, coagulation inhibitors, albumin, immunoglobulins
• large volumes not well tolerated in patient with limited cardiopulmonary reserve, can be associated with TRALI
• efficacy commonly assessed by PT/INR, PTT, fibrinogen level, plt count, viscoelastic tests

Question 6

cryoprecipitate

Answer 6

-slowly thawing FFP leaves behind a cold-insoluble precipitate which contains fibrinogen, FVIII, vWF, and FXIII

Question 7

factor concentrates

Answer 7

• plasma derived

- recombinant

Question 8

blood product administration

Answer 8

• filter + warmer –> PRBCs, FFP, Cryo

- filter only (NO warmer) –> plts

Question 9

plasma derived factor concentrates

Answer 9

• Riastap
• Profilnine
• KCentra

Question 10

recombinant factor concentrates

Answer 10

Factor VIIa, Factor IX

Question 11

Plasma Derived Fibrinogen Concentrate drug

Answer 11

Ristap

Question 12

Ristap MOA

Answer 12

fractionated from blood and stored at room temp for up to 30 months

Question 13

Ristap dose/route

Answer 13

concentrate standardized in each vial (900-1300 mg per 50 mL vial)

Question 14

Ristap admin considerations

Answer 14

quickly reconstituted and administered IV with no thawing or blood type matching required

Question 15

Factor Complex Concentrates drugs

Answer 15

Kcentra – 4 factor

Profilnine – 3 factor

Question 16

Factor Complex Concentrates uses

Answer 16

• reverse effects of significant vitamin K-antagonism
• emergent or urgent surgery
• clotting deficiency

Question 17

Factor Complex Concentrates contraindications

Answer 17

DIC and HIT

Question 18

3 Factor Concentrate Profilnine MOA

Answer 18

complex concentrate which contains factors IX, II, X and low levels of VII

Question 19

3 Factor Concentrate Profilnine dose

Answer 19

10-15 units/IBW kg; max dose 1000 units

Question 20

3 Factor Concentrate Profilnine uses

Answer 20

• hemophilia B treatment

- reserved for cardiac cases

Question 21

4 Factor Concentrate Kcentra MOA

Answer 21

contains antithrombotic proteins C and S and heparin; also factors II, VII, IX, and X

Question 22

4 Factor Concentrate Kcentra uses

Answer 22

• reversal of vitamin K antagonists with INR > 1.5 and experiencing acute major bleeding
• potential to reverse factor Xa inhibitors

Question 23

4 Factor Concentrate Kcentra risks

Answer 23

potential for increased risk of thrombosis in some settings, particularly in patients who do not have hemophilia

Question 24

Recombinant Activated Factor VII drug

Answer 24

Novoseven

Question 25

Novoseven composition

Answer 25

- form of blood factor VII | - glycoprotein produced by recombinant DNA technology

Question 26

Novoseven MOA

Answer 26

-activated form of factor VII, causes coagulation without the need for factors VIII and IX -promotes hemostasis by activating the extrinsic pathway of coagulation cascade -theoretically, localizes action of factor VIIa to the site of injury 2 pathways: -site of tissue injury combine with tissue factor directly activate factor X -platelet surface

Question 27

Novoseven PK/PD

Answer 27

E ½ 2-2.5 hours

Question 28

Novoseven dose

Answer 28

- highly variable 20-200 mcg/kg - 90 mcg/kg IV (most places use this dose) - reconstitute with sterile water - re-dose Q2H

Question 29

Novoseven clinical use

Answer 29

- hemophilia A (deficiency of VIII) - hemophilia B (deficiency of IX) - congenital factor VII deficiency - off label for prevention and treatment of major blood loss

Question 30

Novoseven risks/considerations

Answer 30

- risk of thrombotic adverse events - will not stop surgical hemorrhage - reduce need for transfusion in patients with hemorrhagic shock from blunt trauma - should not be given instead of other blood products, adequate FFP, cryo, and plts need to be present - provide faster correction of coagulopathy - less risk of infectious and noninfectious transfusion reactions - dosing requires hematology and pharmacy consultations