VTE formulary

Question 1

Unfractionated heparin bran

Answer 1

UFH

Question 2

Exonaparin brand

Answer 2

Lovenox

Question 3

Dalteparin brand

Answer 3

Fragmin

Question 4

Tinzaparin brand

Answer 4

Innohep

Question 5

Fondaparinux brand

Answer 5

Arixtra

Question 6

Rivaroxaban brand

Answer 6

Xarelto

Question 7

Edoxaban brand

Answer 7

Savaysa

Question 8

Apixaban brand

Answer 8

Eliquis

Question 9

Bivalirudin brand

Answer 9

Angiomax

Question 10

Dabigatran brand

Answer 10

Pradaxa

Question 11

tPA, Alteplase brand

Answer 11

Activase

Question 12

Reteplase brand

Answer 12

Retevase

Question 13

Tenecteplase brand

Answer 13

Tnkase

Question 14

Urokinase brand

Answer 14

Abbokinase

Question 15

Warfarin bran

Answer 15

Coumadin, Jantoven

Question 16

UFH dose

Answer 16

IV or SQ (not IM)
Old standard: 
5000 u IV bolus + 1000-1200units/hour
Subcutaneous:
Prophylaxis—5000 u SQ q8-12h (12 if less than 50mL/min CrCl)
Treatment—17500 u SQ q12h
Weight based (recommended):
(80 u)/(kg actual body weight) IV bolus + 18 u/kg/hr inf.

Question 17

UFH SE

Answer 17

Major bleeding
Osteoporosis (if long term)
Hypersensitivity
HIT
HAT

Question 18

UFH monitoring

Answer 18

aPTT (therapeutic range 1.5-2.5 times normal)
•Baseline
•6 hours after dose or dose change (x24h)
•`Daily after 1st day

Platelet QOD until day 14

Question 19

lovenox dosing

Answer 19

Prophylaxis:
30mg SQ q12h
40mg SQ daily
Treatment: (actual body weight)
1mg/kg SQ q12h
1.5mg/kg SQ daily
If CrCl less than 30mL/min:
Prophylaxis—30mg SQ daily
Treatment—1mg/kg SQ daily

Question 20

dalteparin dosing

Answer 20

Prophylaxis:
2500-5000 IU SQ daily
Treatment:
200 IU/kg SQ daily (MAX 18000 IU)

Question 21

tinzaparin dosing

Answer 21

Treatment:

175 anti-Xa IU/kg SQ daily

Question 22

enoxaparin, dalteparin and tinzaparin SE

Answer 22

Black box warning:
Do NOT use with neural anesthesia/spinal puncture.

Bleeding
Thrombocytopenia (less than UFH)
Delayed HS skin reactions

Question 23

enoxaparin, dalteparin and tinzaparin monitoring

Answer 23

If CrCl less than 30mL/min (severe kidney failure), children, obesity, long courses, pregnancy, monitor anti-Xa level 4-6h post.

• -BID goal 0.6-1u/mL peak
• -QD goal 0.1-0.3u/mL trough (or 1-2u/mL peak)

Goal 0.5-1.5 in dalteparin less than 30mL/min CrCl.

Question 24

fondaparinux dosing

Answer 24

Prophylaxis:
2.5mg SQ daily (not for less than 50kg or CrCl less than 30mL/min)
Treatment:
less than 50kg: 5mg SQ daily
50-100kg: 7.5mg SQ daily
over 100kg: 10mg SQ daily

Question 25

fondaparinux SE

Answer 25

bleeding

Question 26

fondaparinux monitoring

Answer 26

Can monitor anti-Xa levels, but no routine monitoring

Question 27

rivaroxaban dosing

Answer 27

DVT prophylaxis: (6-10h post surgery) 10mg PO daily for 35 days in THA, 12 dahs TKA DVT/PE treatment: 15mg PO BID x3 weeks, then 20mg daily with food NV Atrial fibrillation: 20mg PO daily (15mg if CrCl 15-50mL/min) Secondary prevention: 20mg PO daily for 6-12 mos, after initial 6-12 mo tx

Question 28

rivaroxaban SE

Answer 28

Bleeding | Black box spinal/epidural hematoma and premature D/C increases risk thrombotic event

Question 29

edoxaban dosing

Answer 29

DVT/PE treatment (after 5-10 days parenteral therapy): 60mg PO daily if CrCl >50 mL/min 30mg PO daily if CrCl 15-50 mL/min, body weight ≤60kg, or Pgp inhibitors NV atrial fibrillation: 60mg PO daily if CrCl 50-95 mL/min 30mg PO daily if CrCl 15-50 mL/min

Question 30

edoxaban SE

Answer 30

Bleeding Black box spinal/epidural hematomas, premature discontinuation increases risk thrombotic event Less efficacy in NVAF patient CrCl >95 mL/min

Question 31

apixaban dosing

Answer 31

DVT prophylaxis: 2.5mg PO BID DVT/PE treatment: 10mg PO BID x7 days, then 5mg BID x6 mos (2.5 after) NV atrial fibrillation: 5mg PO BID 2.5mg PO BID if 2 of: age at or above 80 years, weight 60kg or less, SCr 1.5mg/dL or higher OR dialysis + age over 80 years OR weight under 60kg

Question 32

apixaban SE

Answer 32

Bleeding | Black box spinal/epidural hematomas, premature discontinuation increases risk thrombotic event

Question 33

lepirdin dosing

Answer 33

HIT: | 0.15 mg/kg/h (± 0.4 mg/kg bolus)

Question 34

lepirudin SE

Answer 34

bleeding

Question 35

lepirdun monitoring

Answer 35

Goal aPTT 1.5-2.5 | Reduce dose if CrCl less than 60mL/min

Question 36

bivalirudin dosing

Answer 36

HIT or UFH alternative during PCI: | 0.7 mg/kg bolus + 1.75 mg/kg/h infusion

Question 37

bivalirudin SE

Answer 37

bleeding

Question 38

argatroban dosing

Answer 38

HIT: 2 mcg/kg/min 0.5 mcg/kg/min if hepatic insufficiency

Question 39

argatroban SE

Answer 39

bleeding

Question 40

argatroban monitoring

Answer 40

Elevates INR falsely; overlap with warfarin until INR ≥4

Question 41

dabigatran dosing

Answer 41

``` DVT/PE treatment after 5-10 days parenteral anticoag: 150mg PO BID for CrCl ≥30 mL/min NV atrial fibrillation: 150mg PO BID if CrCl >30 mL/min 75mg PO BID if 15-30 mL/min ```

Question 42

dabigatran SE

Answer 42

Dyspepsia Bleeding Keep in manufacturer bottle

Question 43

dabigatran monitoring

Answer 43

do not use in > 75

Question 44

alteplase dosing

Answer 44

10mg IV bolus + 90mg infusion over 2 hours | Most commonly for PE

Question 45

alteplase SE

Answer 45

bleeding

Question 46

reteplase dosing

Answer 46

10 units IV over 2 minutes + second dose in 30 mins | For ACS only

Question 47

reteplase SE

Answer 47

bleeding

Question 48

tenecteplase dosing

Answer 48

30mg + 5mg/10kg over 60kg up to 50mg as IV bolus | For ACS only

Question 49

tenecteplase SE

Answer 49

bleeding

Question 50

urokinase dosing

Answer 50

VTE treatment: 4400 units/kg bolus over 10 minutes + 4400 units/kg/hour for 12 hours

Question 51

urokinase SE

Answer 51

bleeding

Question 52

warfarin SE

Answer 52

bleeding | pregnancy X

Question 53

warfarin monitoring

Answer 53

CYP2C9, 3A4, 2C19, 1A2 interactions Goal INR 2.0 – 3.0 *mechanical mitral/caged ball/high risk artificial valve goal INR 2.5 - 3.5