VTE

Question 1

NOACs

Answer 1

Factor Xa Inhibitors

Rivaroxaban (Xarelto)
Apixaban (Eliquis)
Edoxaban (Savaysa)

Question 2

DOACs

Answer 2

Direct Thrombin Inhibitor

Dabigatran etexilate (Pradaxa)

Question 3

Postoperative Prophylaxis

Answer 3

Dabigatran has a maintenance dose of 220 mg daily (total duration of therapy: 28-35 days)

Dabigatran is also only for hip replacement only

Rivaroxaban and Apixaban are for knee and hip replacement

Question 4

Non-Valvular Atrial Fibrillation (Dosing)

Answer 4

Dabigatran: 150 mg BID
Rivaroxaban: 20 mg daily
Apixaban: 5 mg BID
Edoxaban: 60 mg PO daily

APIXABAN IS THE ONLY ONE THAT DEPENDS ON SCR AND NOT CRCL

Edoxaban: if CrCl > 95 mL/min use is not recommended

Question 5

DVT/PE Treatment (Dosing)

Answer 5

0-6 months indication

Dabigatran and Edoxaban requires 5-10 days parenteral anticoagulation

Rivaroxaban: 15 mg BID x 3 weeks, then 20 mg daily

Apixaban: 10 mg BID for 7 days, followed by 5 mg BID

Question 6

Secondary Prevention of Recurrent DVT/PE (Dosing)

Answer 6

Month 6 decide if we want to continue or not

Rivaroxaban and Apixaban: After initial 6 months of treatment

Question 7

VTE Prophylaxis

Answer 7

Acute medically ill patient in hospital

Rivaroxaban: 10 mg PO daily

Avoid use: CrCl < 30 ml/min

Question 8

Warfarin Dosing

Answer 8

Variable over time
Variable between patients
Initial dose: 5 mg po daily
Healthy Outpatients: 10 mg daily x 2 days

OVERLAP WITH UFH, LMWH/XA FOR AT LEAST 5 DAYS AND UNTIL INR IS THERAPEUTIC

Question 9

Recommended INR goals

Answer 9

Prophylaxis of VTE: 2-3
Treatment of VTE or PE: 2-3
Prevention of systemic embolism: 2-3
Antiphospholipid antibody syndrome: 2-3
Mechanical heart valve (aortic) : 2-3

Aortic valve replacement- Mechanical On-X: 1.5-2
Mechanical heart valve (mitral, caged ball, high risk): 2.5-3.5

Question 10

Frequency of INR monitoring and patient assessment

Answer 10

Flexible initiation method: daily through day 4, then within 3-5 days
Average daily dosing method: within 3-5 days, then within one week
After hospital discharge: if stable, within 3-5 days, if unstable, within 3 days
First month of therapy: weekly

Question 11

Maintenance Therapy

Answer 11

Dose held today: within 1-2 weeks
Dose change today: within 1-2 weeks
Dosage change < or equal to 2 wks ago: with 2-4 weeks
Routine follow-up stable pt: every 4-6 wks
Consistently stable (no change in 6 months): every 12 weeks

Question 12

Patient Interview

Answer 12

The 5 D’s

Drugs
Diseases
Doses
Diet
Drink

Bruising/Bleeding

Question 13

Dosage Adjustment

Answer 13

S/S of bleeding
Thromboembolic complications
Prescription medication changes
Diet
Activity
EtOH use
Adverse Effects
OTC drug use
Drug interaction screening

Question 14

Dose Alteration for INR 2.0-3.0

Answer 14

INR < 2.0: Increase by 5-15%
INR 3.1-3.5: Decrease by 5-15%
INR 3.5-4.0: Hold 0-1 dose AND/OR Decrease by 10-15%
INR > 4.0: Hold 0-2 doses AND/OR Decrease by 10-15%

Question 15

Dose Alteration for INR 2.5-3.5

Answer 15

INR < 2.5: Increase by 5-15%
INR 3.6-4.0: Decrease by 5-15%
INR 4.1-4.5: Hold 0-1 dose AND/OR Decrease by 10-15%
INR > 4.5: Hold 0-2 doses AND/OR Decrease by 10-15%

Question 16

Warfarin Dosing Example

Answer 16

1. Add up weekly dose
2. Find out if there is a day of the week the pt is taking a different dose
3. MON, WED, FRI

HALF TABLET INCREMENTS
5 MG SO HALF OF 5 IS 2.5 MG

Question 17

Invasive Procedures

Answer 17

Not needed for new anticoagulants

Typically not needed for dental, dermatologic, or cataract procedures

If bridging is needed: stop warfarin 5 days before surgery
Give LMWH or UFH until procedure
Stop LMWH 24 hours before procedure
Stop IV UFH 4-6 hours before procedure

Resume warfarin 12-24 hours after surgery