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Flashcards in Final part 3 Deck (50):
1

Heparin MOA

binds with antithrombin to inactivate factors 10 & 2
- also 9, 11 & 12

2

no renal dose adjustments for

heparin & warfarin

3

prior to initiation of heparin therapetic doses must know:

indication
total body weight
baseline aPTT/anti-Xa & plts
- double check hgb

4

heparin for VTE

80u/kg then 18u/kg/hr

5

heparin for ACS

60u/kg then 12 u/kg/hr

6

heparin for VTE prophylaxis

500u SQ Q8-12H

7

heparin aPTT monitoring

may stop Q6H monitoring after 2 aPTTs in range & go to daily checks
- plts Q3 days

8

prophylactic monitoring for heparin

none

9

lovenox generic

enoxaparin

10

lovenox MOA

binds antithrombin to inactivate factors (X>II)

11

dosing considerations of enoxaparin

indication
renal function
total body weight

12

therapeutic dosing for enoxaparin

- 1mg/kg Q12H if CrCl>30
- QD if CrCl

13

VTE prophylaxis enoxaparin dose

- medical/surgical:40mg SQ QD
- knee replacement: 30 SQ BID
- CrCl

14

enoxaparin monitoring

- anti-Xa
- indicated with treatment doses in:
prego, wt 190kg
- CrCl

15

enoxaparin anti-Xa level targets

- Q12H CrCl>30 or QD CrCl 30:1-2
- prophylaxic: 0.2-0.6

16

fragmin generic

dalteparin

17

dalteparin MOA

binds with antithrombin to inactivate factors X>II

18

dalteparin prophylaxis dosing

500u SQ daily

19

what is the agent of choice for reversal of heparinoids?

protamine sulfate

20

arixtra generic

fondaparinux

21

fondaparinux indications

- VTE prophylaxis: 2.5mg SQ QD
- VTE treatment: (100:10mg)
- CI in CrCL

22

MOA of argatroban

direct thrombin inhibitor

23

argatroban indications

- prevention/treatment of HIT
- PCI

24

argatroban monitoring

- aPTT
- prolongs INR

25

consider addition of warfarin to argatroban infusion when:

confirmed HIT PLUS plts >150

26

overlap warfarin & argatroban for

at least 5 days before dc argatroban

27

angiomax generic

bivalirudin

28

bivalirudin MOA

direct thrombin inhibitor

29

bivalirudin dosing

- PCI: 0.75mg/kg x1 then 1.75mg/kg/hr
- HIT:0.15-0.2mg/kg/hr

30

bivalirudin monitoring

- HIT: aPTT levels
- PCI: once time ACT

31

peri-operative for heparin

hold 4-6 hours before surgery & weight 48-72 hours after for high risk bleeders (24 for non-high risk)

32

peri-operative for LMWH

- 24 hours before & 24 hours after

33

warfarin MOA

- inhibits vitamin K epoxide reductase (VKOR) complex to reduce vitamin K available for the synthesis of SNOT, & Protein C & S

34

warfarin initial dose

5mg PO QD (5-10)
- may use 10mg x 2 day loading dose if healthy

35

sensitivity factors for warfarin

- use 2.5mg QD
- age over 75
-liver or renal disease
- HF
- high bleeding risk
- drug interaction
- acute etOH intake
- smoking cessation
-poor nutritional status
- infection
-malignancy

36

cyp2c9 & Vkorc1 genotyping

- currently not recomended

37

agents that increase warfarin efficacy & bleeding

amiodarone
fluconazole
metronidazole
NSAIDs
sulfonamides
"G" herbals
other anticoags

38

agents that decrease warfarin efficacy

rifampin
st johns wort
carbamazepine

39

INR measures factors

II, VII, & X

40

warfarin titration

INR:
-less than1.5: incr wk 10-20%
- 1.5-1.9:incr wk 5-15%
- 2-3 continue
- 3.1-3.5: decr wk 5-15
-3.6-4.4: dec 10-20% & hold 2 doses
- more than 4.5: follow flow chart

41

warfarin INR follow up times

- initiation (outpt): 5-7 days
- out of range (less than 4.5) or 1 INR in range: 1-2 wks
- 2 or more in range: 4 wks
- severe bleeding: PRN
- INR more than 10: 1-2 days
- INR 4.5-10: 2-3 days

42

warfarin bridging therapy is most appropriate in:

VTE, Afib & valve replacement
- initiate warfarin & IV anticoag on day 1
- for at least 5 days until 2 INRs are above 2 24 hours apart

43

pradaxa generic

dabigatran
- direct thrombin inhibitor

44

pradaxa dosing

- 150mg PO BID
- must complete 5-10 days IV
- DVT or nonvalv AF

45

xarelto generic

rivaroxaban
- factor Xa inhibitor

46

xarelto dosing

- acute DVT: 15mg PO BID x21 then 20mg QD
- nonvalv: 20mg QD
- prophylaxis: 10mg QD

47

eliquis generic

apixaban
- factor Xa inhibitor

48

eliquis dosing

- DVT: 10mg PO ID x7 days then 5mg BID
- nonvalv: 5mg BID
- prophylaxis: 2.5mg BID

49

savaysa generic

endoxaban
- factor Xa inhibitor

50

savaysa dosing

- dvt: 60mg QD
- must complete 5-10 days IV
- nonvalv: 60mg qd
- do not use in crcl above 95 or less than 15