Riccios Dosing Info Flashcards
(29 cards)
UFH VTE Prophylaxis dosing
Normal dose
5,000 units SC 8-12 hours
CrCl < 30 mL/min
No change
Hemodialysis
No change
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
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
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
Fondaparinux VTE prophylaxis dose
Arixtra
Normal dose:
2.5 mg SC daily
CrCl 30-50:
50% dose
**** <30 contraindicated
Hemodialysis:
Contraindicated
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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)
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
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
- Once HIT is suspected and high 4t score you stop ALL anticoagulants and start argatroban 2mcg/kg/min CIVI
- Titrate until 1.5-3 times baseline aPPT (max 10mcg/kg) for 3-7 days until platelet count resolves
- Decrease argatroban to 2mcg/kg/min and start warfarin
- Min of 5 day bridging and INR target of >4 (while on both)
- 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
What is the counseling for rivaroxaban?
Xarelto
- May crush/chew
- Doses 15mg or greater require large meal intake
- Missed dose can be taken same day for MAX dose of 30mg PO for VTE TREATMENT ONLY
- Hold dosing 24 hours prior to surgery or invasive procedures
What is the counseling for apixaban?
Eliquis
- May crush or chew if mixed with 60 mL D5W
- With or without food
- No double dosing if missed dose
- Hold dosing for 48 hours prior to moderate or high risk bleeding surgery or invasive procedures; hold 24 hours with mild/low risk
