VTE Lab Formulary

Question 1

Enoxaparin brand name

Answer 1

Lovenox

Question 2

What is the prophylactic dose of enoxaparin?

Answer 2

30mg SQ BID
40mg SQ daily
If CrCl less than 30mL/min:
30mg SQ daily

Question 3

What is the treatment dose of enoxaparin?

Answer 3

1mg/kg SQ BID
1.5mg/kg SQ daily
If CrCl less than 30mL/min:
1mg/kg SQ daily

Question 4

What is the anti-Xa goal in patients on BID enoxaparin? Daily enoxaparin?

Answer 4

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

Question 5

Dalteparin brand name

Answer 5

Fragmin

Question 6

What is the prophylactic dose of dalteparin?

Answer 6

2500-5000 IU SQ daily

Question 7

What is the treatment dose of dalteparin?

Answer 7

200 IU/kg SQ daily (MAX 18000 IU)

Question 8

What is the anti-Xa goal in patients with CrCl

Answer 8

0.5-1.5 u/mL

Question 9

Tinzaparin brand name

Answer 9

Innohep

Question 10

What is the treatment dose of tinzaparin?

Answer 10

175 anti-Xa IU/kg SQ daily

Question 11

Fondaparinux brand name

Answer 11

Arixtra

Question 12

What is the prophylactic dose of fondaparinux?

Answer 12

2.5mg SQ daily (not for patients less than 50kg or CrCl less than 30mL/min)

Question 13

What are the treatment doses of fondaparinux (broken up by weight)?

Answer 13

Less than 50kg: 5mg SQ daily
50-100kg: 7.5mg SQ daily
Over 100kg: 10mg SQ daily

Question 14

What are the two possible routes of unfractionated heparin administration?

Answer 14

IV or SQ (not IM)

Question 15

What lab is monitored for UFH therapy?

Answer 15

aPTT (therapeutic range 1.5-2.5x normal)

Question 16

How often is aPTT monitored in UFH therapy?

Answer 16

At baseline, 6 hours after dose or dose change, daily after 1st day.

Question 17

How is UFH dosed using a weight based approach?

Answer 17

80 units/kg IV bolus + 18 units/kg/hr infusion

Question 18

How is UFH dosed subcutaneously prophylactically?

Answer 18

5000 unit IV bolus + 1000-1200 units/hour

Question 19

How is UFH dosed subcutaneously for treatment?

Answer 19

17500 units SQ BID

Question 20

Rivaroxaban brand name

Answer 20

Xarelto

Question 21

How is rivaroxaban dosed for DVT prophylaxis?

Answer 21

10mg PO daily for 35 days in THA, 12 days in TKA

Question 22

How is rivaroxaban dosed for DVT/PE treatment?

Answer 22

15mg PO BID x 3 weeks then 20mg PO daily with food

Question 23

How is rivaroxaban dosed for NV atrial fibrillation?

Answer 23

20mg PO daily (15mg if CrCl 15-50mL/min)

Question 24

How is rivaroxaban dosed for secondary prevention of VTE after initial appropriate 6 month therapy?

Answer 24

20mg PO daily for 6-12 mos

Question 25

Edoxaban brand name

Answer 25

Savaysa

Question 26

How is edoxaban dosed for DVT/PE treatment after 5-10 days of parenteral therapy?

Answer 26

CrCl 50mL/min or greater: 60mg PO daily | CrCl 15-50mL/min, weight

Question 27

How is edoxaban dosed for NV atrial fibrillation?

Answer 27

CrCl 50-95 mL/min: 60mg PO daily | CrCl 15-50mL/min: 30mg PO daily

Question 28

Apixaban brand name

Answer 28

Eliquis

Question 29

How is apixaban dosed for DVT prophylaxis?

Answer 29

2.5mg PO BID

Question 30

How is apixaban dosed for DVT/PE treatment?

Answer 30

10mg PO BID x7 days, then 5mg BID x6 mos (2.5 after)

Question 31

How is apixaban dosed for NV atrial fibrillation?

Answer 31

5mg PO BID unless... 2 of age >80, weight less than 60kg, or SCR 1.5mg/dL or greater OR dialysis + age >80 or weight less than 60kg

Question 32

Dabigatran brand name

Answer 32

Pradaxa

Question 33

How is dabigatran dosed for DVT/PE treatment after 5-10 days of parenteral anticoagulation?

Answer 33

150mg PO BID for CrCl >30mL/min

Question 34

How is dabigatran dosed for NV atrial fibrillation?

Answer 34

CrCl >30mL/min: 150mg PO BID | CrCl 15-30mL/min: 75mg PO BID

Question 35

What is one patient counseling point for dabigatran?

Answer 35

Keep in manufacturer bottle and not in humid places

Question 36

How is lepirudin dosed?

Answer 36

0.15mg/kg/h (with or without 0.4mg/kg bolus) | Reduce if CrCl

Question 37

What is the target aPTT with lepirudin?

Answer 37

1.5-2.5 normal

Question 38

Bivalrudin brand name

Answer 38

Angiomax

Question 39

How is bivalrudin dosed?

Answer 39

0.7mg/kg IV bolus + 1.75 mg/kg/h infusion

Question 40

How is argatroban dosed?

Answer 40

2mcg/kg/min or 0.5mcg/kg/min if hepatic insufficiency

Question 41

What is an important clinical pearl for argatroban?

Answer 41

Falsely elevates INR--overlap with warfarin until INR >4

Question 42

tPA (alteplase) brand name

Answer 42

Activase

Question 43

How is alteplase dosed?

Answer 43

10mg IV bolus + 90mg IV infusion over 2 hours

Question 44

Reteplase brand name

Answer 44

Retevase

Question 45

How was reteplase dosed?

Answer 45

10 units IV over 2 minutes + second 10 unit dose in 30 minutes

Question 46

Tenecteplase brand name

Answer 46

TNKase

Question 47

How is tenecteplase dosed?

Answer 47

IV bolus of 30mg + 5mg/10kg over 60kg. MAX 50mg.

Question 48

Brand name for urokinase

Answer 48

Abbokinase

Question 49

How is urokinase dosed?

Answer 49

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

Question 50

Warfarin brand names

Answer 50

Coumadin, Jantoven

Question 51

What is an appropriate starting dose for warfarin if no other factors are known?

Answer 51

5mg PO daily

Question 52

What is the goal INR on warfarin therapy?

Answer 52

2. 0 - 3.0 | * except for mechanical mitral/caged ball/high risk valve--2.5-3.5*

Question 53

What is an appropriate action if a patient's INR is 3.2 on warfarin?

Answer 53

Decrease weekly dose by 5-15% if no clear cause

Question 54

What is an appropriate action if a patient's INR is 3.7 on warfarin?

Answer 54

Hold 0-1 dose and decrease weekly dose by 10-15% if no clear cause

Question 55

What is an appropriate action if a patient's INR is 1.5 on warfarin?

Answer 55

Increase weekly dose by 5-15%

Question 56

What is an appropriate action if a patient's INR is 4.1 on warfarin?

Answer 56

Hold 0-2 doses and decrease weekly dose by 10-15% if no clear cause

Question 57

What is a major genetic source of warfarin pharmacokinetic variability?

Answer 57

Variation in CYP2C9 expression

Question 58

How soon should an INR be checked if a patient's dose was held today?

Answer 58

In 1-2 days

Question 59

How soon should an INR be checked if a patient's warfarin dose was changed today?

Answer 59

Within 1-2 weeks

Question 60

What is the longest you can go without checking an INR in a patient stable on one warfarin dose for 6 months?

Answer 60

Every 12 weeks