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Flashcards in Riccios Dosing Info Deck (29)
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1

UFH VTE Prophylaxis dosing

Normal dose
5,000 units SC 8-12 hours

CrCl < 30 mL/min

No change

Hemodialysis
No change

2

Dalteparin VTE Prophylaxis dosing

Fragmin

Normal dose:
2,500 units SC daily
5,000 units SC daily

CrCl < 30 mL/min
50% reduction in dose

Hemodialysis:
Use UFH

3

Enoxaparin VTE prophylaxis treatment

Lovenox

Normal dose:
30 mg SC BID (ONLY FOR ORTHO SURGERY)
40 mg SC QD

CrCl < 30 mL/min
30 mg SC daily

Hemodialysis:
Use UFH

4

Tinzaparin VTE prophylaxis treatment

Innohep

Normal dose:
3,500 units SC daily
4,500 units SC daily

CrCl 30-50 mL/min:
25% dose reduction
***IF CrCl < 30 its contraindicated

Hemodialysis:
Use UFH

5

Fondaparinux VTE prophylaxis dose

Arixtra

Normal dose:
2.5 mg SC daily

CrCl 30-50:
50% dose
****** <30 contraindicated

Hemodialysis:
Contraindicated

6

Rivaroxaban VTE prophylaxis dose

Xarelto

Normal dose:
10mg PO daily

CrCl < 30 mL/min
Contraindicated

Hemodialysis:
Contraindicated

****Knee surgery at least 10-14 days
For xarelto its 12 days and for hip surgery is 35 days

7

Apixaban VTE prophylaxis dosing

Eliquis

Normal dose:
2.5 mg PO BID

**** avoid in patient taking strong CYP3A4 or P-gp inhibitors

Knee surgery = 12 days

Hip surgery = 35 days

8

Warfarin VTE treatment dosing

Anticoagulants, Coumadin and Jantoven

MOA:
Vit K antagonist, blocks production of factors 1972 and proteins C and S.
CYP metabolism: 2C9
Half-life: 1 week, may take 3 days to start to se effect of change an d8-15 days to see full effect

Normal dose:
Bridge > 5 days with parental until therapeutic and stable (INR > 2 for 2 readings
— 5-20% dose reduction and/or hold if supratheraputic
— 5-20% dose increase if sub-therapeutic

Renal dose: no change

Monitoring
Pt/INR
INR goal = 2-3
High goal = 2.5- 3.5 in patients with MITRAL mechanical valve
BIW-TIW for 1-2 weeks then every 1-3 months once stable

Contraindications:
Pregnancy
Active bleeds
Non-compliance
Frequent falls

9

UFH VTE treatment dosing

Anticoagulants
MOA:
Potentiates ATIII which inhibits factors Xa and IIa
Half-life: 30-150 minutes
High protein binding with variable response

Normal Dose:
80 units/kg bolus followed by 18 units/kg/hour
**LD required to expedite onset of action —> reduces morbidity/mortality from DVT/PE

Renal dosing: NO CHANGE

Monitoring:
Appt: 1.5-2 x baseline
ACT (bedside)
Anti-FXa - 0.3-0.7
Platelets

10

Dalteparin VTE treatment dosing

LMWH, Fragmin

MOA:
Potentiates ATIII, inhibits FXa > FIIa
Half-life = 3-5 hours SC

Normal dose:
100 units/kg SC bid
200 units/kg SC daily

CrCl < 30
100 units/kg daily

Monitoring
Look for anti-factor Xa to be 1 four hours as dose in patients in obesity, pregnancy, pediatric and renal impairment
Scr and platelets

11

Enoxaparin VTE treatment dosing

LMWH, Lovenox

MOA:
ATIII FXa> FIIa
Half-life = 7 hours

Normal dose:
1mg/kg SC BID (preferred)
1.5mg/kg SC daily

CrCl < 30:
1mg/kg daily

Monitoring
Look for anti-factor Xa to be 1 four hours as dose in patients in obesity, pregnancy, pediatric and renal impairment
Scr and platelets

12

Tinzaparin VTE treatment dosing

LMWH, Innohep

MOA:
ATIII, FXa > IIa
Half-life: 3-4 hours

Normal dosing:
175 units/kg SC daily

CrCl < 30
25% dose decrease

Monitoring
Look for anti-factor Xa to be 1 four hours as dose in patients in obesity, pregnancy, pediatric and renal impairment
Scr and platelets

13

Fondaparinux VTE treatment dosing

Synthetic pentasaccharide, Arixtra

MOA:
ATIII exclusive to FXa
Half-life = 17-21 hr

Normal dosing:
<50kg : 5 mg SC daily
50-100 kg: 7.5 mg SC daily
>100kg: 10 mg SC daily

CrCl < 50
50% reduction

Monitoring:
Scr

Contraindications:
CrCl < 30 ml/min
Hemodialysis

14

Rivaroxaban VTE treatment dose

Direct anti-factor Xa, Xarelto

MOA:
Direct antiFXa; free P-gp & CYP
Half-life = 5-12 hrs

Normal dose:
15mg PO BID with food for 21 days, then 20mg PO daily with food

Contraindications:
CrCl < 30 mL/min
Hemodialysis
Child-Pugh B/C

15

Apixaban VTE treatment dosing

Direct Anti-factor Xa, Eliquis

MOA:
Direct AntiXa; free & clot P-gp & CYP
Half-life = 12 hrs

Normal dosing:
10mg BID for 7 days, then 5mg BID up to 6 months, then 2.5mg BID if extended

Contraindications:
With CYP3A4 or P-gp inhibitors

16

Edoxaban VTE treatment dose

Direct Anti-FXa, Savaysa

MOA:
Direct AntiFXa; free & clot P-gp

Normal dose:
60mg daily after 5-10 days of parental anticoagulant

if <60kg or CrCl is 15-50 mL/min
30mg Daily

Contraindications
CrCl < 15 mL/min
Child-Pugh B/C

17

Dabgatran VTE Treatment dose

Direct Thrombin inhibitor, Pradaxa

MOA:
DTI free and clot-bound
Half-life = 12-17 hours

Normal Dosing:
150mg BID after 5-10 days of parental anticoagulants

Avoid in CrCl < 30 mL/min

Monitor:
Scr

Contraindications:
CrCl < 30 mL/min
CrCl < 50 with P-pg inhibitors

18

Duration of VTE treatments

1st event
Reversible known cause: 3 months (usually 2-3 months required for internal clot to dissolve)
Irreversible or unknown cause: 3-6 months

Recurrent VTE: Extended duration; route re-evaluation

DVT and cancer: LMWH for 3 months; may convert to VKA until Ca remission

19

What is Protamine used for and its dosing?

It’s a reversal agent for UFH as well as for LMWH

100 units UFH
Within 30 minutes - 1 mg
Between 30-120 minutes - 0.5 mg
> 120 minutes - 0.25 mg

1 mg enoxaparin, 100 units dalteparin/tinzaparin
Within 8 hours - 1mg protamine
Between 8-12 hours - 0.5 mg protamine
> 12 hours - do not use

20

What is Praxbind used for and what’s it dosing?

It’s used as a reversal agent for dabigatran

Dosing:

2.5mg IV bolus/infusion, repeat 2nd dose within 15 minutes (5mg total)

21

What is Andexanet Alfa used for and its dosing?

Andexxa, its used as a reversal agent for Xarelto (rivaroxaban) and Eliquis (Apixaban)

Dosing:
Low dose: 400mg IV bolus, then 4mg/min CIVI up to 120 min
High dose: 800mg IV bolus, then 8mg/min CIVI up to 120 minutes

22

What is a reason to use argatroban in a patient and what’s the procedure its done in?

You use argatroban for patients who have HIT

1. Once HIT is suspected and high 4t score you stop ALL anticoagulants and start argatroban 2mcg/kg/min CIVI

2. Titrate until 1.5-3 times baseline aPPT (max 10mcg/kg) for 3-7 days until platelet count resolves

3. Decrease argatroban to 2mcg/kg/min and start warfarin

4. Min of 5 day bridging and INR target of >4 (while on both)

5. Hold the argatroban for 4-6 hours to evaluate INR, >2 you stop argatroban and go full warfarin. If INR <2 you restart argatroban and try again the next day

23

What is the counseling for rivaroxaban?

Xarelto

1. May crush/chew

2. Doses 15mg or greater require large meal intake

3. Missed dose can be taken same day for MAX dose of 30mg PO for VTE TREATMENT ONLY

4. Hold dosing 24 hours prior to surgery or invasive procedures

24

What is the counseling for apixaban?

Eliquis

1. May crush or chew if mixed with 60 mL D5W

2. With or without food

3. No double dosing if missed dose

4. Hold dosing for 48 hours prior to moderate or high risk bleeding surgery or invasive procedures; hold 24 hours with mild/low risk

25

What is the counseling for edoxaban?

Savaysa

1. With or without food

2. No double doing

3. Hold dosing 24 hours prior to surgery or invasive procedures

26

What is the counseling for dabigatran?

Pradaxa

1. Store in original package (do not put pill in organizer) at room temp

2. Once opened, product must be used within 4 months

3. Do not chew crush or open capsules (75% increased bioavailability)

4. Missed doses if >6 hours before dose before next dose

5. Hold 1-2 days (CrCl>50mL/min) prior to surgery or invasive procedure

6. Hold 3-5 days (CrCl<50mL/min) prior to surgery or invasive procedures

27

What will decreases INR in a patient taking warfarin?

Coumadin and Jantoven

1. Missed doses

2. PK inducers: CPR PS

3. Starting a multivitamin (Vit K), increase Vit K intake

4. Decreased alcohol

5. Increased smoking

28

When taking warfarin what will cause no change to INR but increase bleeding risk

1. ASA

2. NASID

3. Fish oil

4. Garlic

5. Vit E

29

When taking warfarin what will cause you to have an increase in INR?

1. Extra doses

2. PK inhibitors: GPACMANS (Bactrim, Levaquin, Simva, Steroids)

3. D/C multivitamin (with Vit K)

4. Decrease Vit K intake

5. Increased alcohol intake

6. Decreased smoking