Therapeutics of Venous Vascular Diseases Flashcards
(62 cards)
1
Q
UFH contraindication
A
- History of HIT
- Hypersensitivity to agent
- Active bleeding
2
Q
LMWH contraindication
A
- History of HIT
- Hypersensitivity to agent
- Active bleeding
3
Q
FONDAPARINUX contraindication
A
- CrCl < 30 mL/min (severe renal dysfunction)
- Fondaparinux-induced thrombocytopenia
- Hypersensitivity
- Active bleeding
4
Q
Warfarin contraindication
A
- Hypersensitivity to warfarin
- Active bleeding, Pregnancy category X
- h/o warfarin-induced skin necrosis or purple toe syndrome
5
Q
Dabigatran contraindication
A
- Hypersensitivity
- Active bleeding
6
Q
Factor Xa inhibitors contraindication
A
- Hypersensitivity
- Active bleeding
7
Q
Contraindications in general to VTE treatment
A
- active bleeding
- hemophilia
- severely uncontrolled hypertension (will increase risk for hemorrhagic stroke)
8
Q
HAS BLED
A
- Hypertension; esp uncontrolled, at risk for brain bleed
- Abnormal renal or hepatic function; will also throw off PK of anticoags
- Stroke (history of)
- Bleeding, history of
- Labile International
- Normalized Ratio (INR) on warfarin therapy
- Elderly (e.g.> 65 years)
- Drugs (e.g. concurrent aspirin, nonsteroidal anti-inflammatory drugs (NSAIDS), or heavy alcohol use)
9
Q
UFH adverse effects
A
- Bleeding (also bruising at injection site)
- Osteoporosis (long-term)
- Thrombocytopenia (mild & severe)
- Mild: platelet count <150k, goes away within a few days, can change med to make sure it’s not HIT
- Severe: HIT, platelets & antibodies, platelet count <100K or drop >50%, requires acute attention, D/C med right away
10
Q
LMWH adverse effects
A
- Bleeding (but < UFH)
- Epidural or spinal hematoma
- HIT (but < UFH)
- D/C med if there’s too much anticoagulation
11
Q
FONDAPARINUX adverse effects
A
- Anemia
- Bleeding
- Mild thrombocytopenia (not HIT)
- D/C med if there’s too much anticoagulation
12
Q
Warfarin adverse effects
A
- Bleeding; most common is GI bleed
- Intracranial hemorrhage
- Purple toe syndrome
- Warfarin-induced skin necrosis
13
Q
Dabigatran adverse effects
A
- Bleeding (fewer ICH, more GI)
- Spinal Hematoma
- Dyspepsia
14
Q
Factor Xa inhibitors adverse effects
A
- Bleeding (fewer ICH, more GI)
- Spinal Hematoma
15
Q
UFH reversal agent
A
Protamine sulfate
16
Q
LMWH reversal agent
A
Protamine sulfate
17
Q
FONDAPARINUX reversal agent
A
None
18
Q
Warfarin reversal agent
A
Vitamin K
19
Q
Dabigatran reversal agent
A
Idarucizumab (Praxbind ®)
20
Q
Factor Xa inhibitors reversal agent
A
Currently under investigation but none developed at this time
21
Q
initial and maintenance dosing principles of warfarin therapy
A
- Start at 5-10 mg for first 1-2 days
- Lower starting dose (i.e. < 5 mg, 2-2.5mg) may be appropriate e.g. elderly (over 65), malnourished, congestive heart failure (CHF), liver disease, concomitant drugs, and “sensitive” genetic genotype/variants
- Steady state should be achieved within 14 days
- Adjustments made by calculating the weekly dose and ↑ or ↓ by 5-20%
22
Q
warfarin interactions
A
- Vit K rich foods
- chewing tobacco
- MVI
- herbals
- cranberry juice in high consumptions
- drugs
- disease
23
Q
warfarin interactions: drugs
A
- NSAIDS, aspirin, clopidogrel, DOACs: can increase bleeding risk
- Cholestyramine: will bind to warfarin and prevent it from being absorbed
- Increase INR: Acute alcohol use, amiodarone, celecoxib, cimetidine, fluconazole, fluoroquinolones, macrolides, metronidazole, omeprazole, simvastatin, trimethoprim/sulfamethoxazole
- Decrease INR: Azathioprine, carbamazepine, rifampin, smoking
24
Q
warfarin interactions: disease
A
- CHF
- Diarrhea
- Vomiting
- Fever
- Hepatic disorders
- Hypo/hyperthyroidism (hypo decreases INR)
- Poor nutritional state
25
What to do pre-surgery if pt has to hold warfarin?
- Stop INR for 5 days -> INR should go down to 1
| - Can bridge with parenteral anticoag if necessary
26
What to do post-surgery if pt held warfarin?
- Resume both once hemostasis reestablished
| - D/C parenteral once INR is reached
27
How do you know when to bridge a patient?
- Bridge: if VTE happened < 3 months or has severe thrombophilia
- Either/Or: VTE within 3-12 months or non severe thrombophilia
- No bridge: single VTE > 12 months ago
28
reversal regimen for warfarin
- Oral – 5mg; reassess in 24-48 hours
- IV – administer 1mg/min max; reassess in 6-12 hours
- SubQ – not recommended
- In doses ≥ 10mg, prolonged warfarin resistance may occur
29
What are the ACCP Guidelines when INR > goal < 4.5 and no bleeding?
Lower or hold next dose & restart at lower dose
30
What are the ACCP Guidelines when INR 4.5-10 and no significant bleeding?
Hold 1-2 warfarin doses
31
What are the ACCP Guidelines when INR > 10 and no significant bleeding?
Hold warfarin PLUS Vitamin K PO 2.5-5 mg
32
What are the ACCP Guidelines when Serious or life-threatening bleeding & elevated INR?
Hold warfarin, Vitamin K IV 510mg, PLUS FFP or PCC
33
anticoagulants that can be used in a patient with several renal dysfunction
- Can use Enoxaparin but dosing interval has to go from q12 to q24 hours
- Apixaban
- Edoxaban can be used in CrCl of 15-95 ml/min
- Betrixaban can be used in CrCl 15-30 ml/min at 40mg daily with food
34
FONDAPARINUX monitoring
- Therapeutic monitoring not required
- If needed, can measure anti-Xa levels
- CBC to monitor for anemia
35
Dabigatran monitoring
- Therapeutic monitoring not required
- Renal function at baseline and every 3-6 months
- CBC at baseline and at least annually
36
Factor Xa inhibitors monitoring
- Therapeutic monitoring not required
- Safety monitoring: renal function at baseline and every 3-6 months
- CBC at baseline and at least annually
- Can measure anti-Xa activity but will only tell us presence / absence, won’t tell us how much
- take with evening meal (high fat and high content) to improve absorption, med adherence is important
37
DOACs Disadvantages
- Many subgroups excluded or underrepresented in trials
- no measureable assay
- cannot use in renal or liver dysfunction
- less flexibility of dosing
- costs more
38
Good candidates for DOAC use
- Pt preference for and willingness to take DOAC
- No contraindications to DOAC
- Good organ function
- No significant drug-drug interactions
- Highly likely to be adherent with DOAC
- Ability to afford DOAC on chronic basis
- Unable to have routine INR monitoring
39
Good candidates for warfarin use
- Pt preference for and willingness to comply with warfarin monitoring
- History of poor medication adherence
- Renal and hepatic impairment
- Other special populations where DOACs haven’t been adequately studied (pediatrics, breastfeeding)
- Cannot afford DOACs
- When avoiding drugs that interact with DOACs is not an option for the patient (due to inability to monitor and dose titrate)
40
4 measures for nonpharmacologic prophylaxis
- Early ambulation
- Intermittent pneumatic compression (IPC)
- Graduated compression stockings (GCS)
- Inferior vena cava (IVC) filter
41
What are the criteria for inferior vena cava filter?
For patients actively bleeding, has high hypertension, or has contraindications to anticoags
42
UFH prophylaxis dose
- 5000 U SC BID or TID
| - TID dosing has shown improved efficacy in some populations over BID dosing
43
LMWH prophylaxis dose
30 mg SC q 12 hours or 40 mg SC q 24 hours
44
Dalteparin prophylaxis dose
2500 U or 5000 U SC q 24 hours
45
FONDAPARINUX prophylaxis dose
2.5 mg SC daily
46
Dabigatran prophylaxis dose
- 110 mg first day, then 220 mg PO daily
| - Avoid if CrCl < 30 ml/min or for patients on dialysis
47
Rivaroxaban prophylaxis dose
10 mg PO daily
48
Apixaban prophylaxis dose
2.5 mg PO daily
49
Betrixaban prophylaxis dose
- 160 mg day 1, then 80 mg daily with food
- If CrCl 15-30 ml/min, then 40 mg daily with food
- Not recommended if CrCl < 15 ml/min
- Specifically for patients in the hospital
50
Enoxaparin treatment dose
- 1 mg/kg subcutaneous (SC) q 12 hours
| - If CrCl < 30 ml/min, reduce to 1 mg/kg SC q 24 hours (renal dysfunction)
51
Rivaroxaban treatment dose
- 15 mg PO BID x 21 days, then 20 mg PO daily with food
- After at least 6 months of initial therapy, can reduce to 10 mg PO daily with food
- Avoid if CrCl < 30 ml/min
52
Apixaban treatment dose
- 10 mg PO BID x 7 days, then 5 mg PO BID
| - After at least 6 months of initial therapy, can reduce to 2.5 mg PO BID
53
Dabigatran treatment dose
- 150 mg PO BID (after 5-10 days of parenteral anticoagulation)
- Avoid if CrCl < 30 ml/min or for patients on dialysis
54
Edoxaban treatment dose
- 60 mg PO daily (after 5-10 days of parenteral anticoagulation)
- 30 mg PO daily if CrCl 15-50 ml/min or weight < 60 kg,(after 5-10 days of parenteral)
- Avoid if CrCl < 15 ml/min or > 95 ml/min
55
UFH monitoring
- aPTT
- Reagent-specific therapeutic aPTT range corresponding to plasma heparin level of 0.2-0.4 IU/mL
- Monitor platelet count every other day until day 14 or until UFH discontinued to monitor development of HITT
56
LMWH monitoring
- Therapeutic monitoring not required
- If needed, can measure anti-Xa levels
- Special populations: children, pregnancy, weight is < 50 kg or > 155 kg
57
Wafarin monitoring
- Follow-up and INR within 3 days, and then follow-up at least every 3-5 days until INR is within the range of 2.0-3.0 for 2 consecutive readings and patient is on a maintenance dose of warfarin.
- Assess INR w/in 7-14 days of dose adjustment
- Assess INR monthly if stable and can extend to every 6-12 weeks if very stable
- CBC annually for safety monitoring
- For maintenance: monitor medication adherence, medication changes, bleeding, thrombosis, dietary changes, social habits (i.e. smoking)
58
UFH treatment dosing
- weight based dosing
| - every hospital has their own protocol
59
FONDAPARINUX treatment dosing
- < 50 kg = 5 mg SC Q 24 hours
- 50-100 kg = 7.5 mg SC Q 24 hours
- > 100 kg = 10 mg SC Q 24 hours
60
How long should therapy of VTE last?
- 3 months: first VTW with reversible or transient factors
- 3 months to indefinite: first VTE, unprovoked
- Indefinite: recurrent VTE
61
What is used for prophylaxis?
- UFH
- LMWH
- Dalteparin
- FONDAPARINUX
- Dabigatran
- Rivaroxaban
- Apixaban
- Betrixaban
62
What is used for treatment?
- Enoxaparin
- Warfarin
- Rivaroxaban
- Apixaban
- Dabigatran
- Edoxaban
