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VTE Prophylaxis Flashcards

1
Q

Prophylaxis goal?

A

Identify patient risk Determine risk level Select the correct regimen pharm and non pharm

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2
Q

Non pharm treatment Therapy for VTE

A

Graduated compression stockings (GCS) - good for low or moderate risk Can wear leg too big - IPC- intermittent pneumatic compression increase circulation

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3
Q

Pharmacologic Prophylaxis

A

Duration is unclear but once patient can ambulate or other RFs are gone then dc therapy - Knee replacement, treatment for 12 days after - Hip replacement 35 days after

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4
Q

Standard dosing for LMWH ?

A

Regardless of weight

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5
Q

Risk Level

A
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6
Q
  • What are the goals for VTE treatment?
A
  • Prevent short term complications within 6 months
      • Prevent extension of clot
        • Prevent embolism clot
        • Prevent death
    • Prevent long term complications past 6 months
      • Post thrombotic syndrome
      • Pulmonary HTN
      • Recurrent VTE
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7
Q

UFH is from?

Does what to clots?

A

From procine stomach or bovine lung

Does not dissove clot but prevents growth

Binds to AT

neutralizes Thrombin factors Xa IX, Xia, XIIa

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8
Q

UFH is administered?

Non specific binding site so?

A

IV and Sub Q

Sub Q onset is 1-2 hours

Poor bioavailability

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9
Q

It is critical to achieve ___ of UFH within the first?

What type of dosing is there?

A

therapeutic dose within 24 hours

Weight base

Standard dose

VTE chart

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10
Q

UFH requires close monitoring and is done by the lab test?

A

Activated partial thromboplastin time (aPTT)

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11
Q

Normal therapeutic range for aPTT?

___ to ___ the control aPTT value

A

28-42 seconds

1.5 to 2.5

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12
Q

Baseline aPTT is done?

A

6 hours after starting UFH infusion and 6 hours have dose change

Takes 6 hours to reach steady state

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13
Q

Adverse effects of UFH/

A
  • Bleeding
  • Thrombocytopenia
    • HIT in 5%
  • Long term use can casue Alopecia, Hyperkalemia, Osteoporosis
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14
Q

HIT

A
  • Is an immune system clotting disorder
    • Formation of abnormal antibodies cause platelet activation
  • Monitor platelets every 2-3 days during UFH therapy
  • If platelets fall below 50% from baseline or below 120000 think HIT
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15
Q

UFH antidote?

A

Protamine

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16
Q

UFH is ok to using in ___ patients

if patient is ____

Contraindication?

A

Pregnant

Can breastfeed

Contraindication is Hx of HIT

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17
Q

LMWH

A

Binds to Xa not much to do with thrombin

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18
Q

Advantages of LMWH?

A
  • The anticoagulant response is more predictable less binding to plasma and cellular proteins
    • Reduced need for monitoring
  • Improved SUB Q bioavailability
  • Longer half life
  • Lower chance of HIT
  • Lower chance of osteoporosis
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19
Q

LMWH products

Parin, Parin, Parain

A

Dalteparin

Enoxaparin

Tinzaparain

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20
Q

LMWH has much greater effect on ___

but a draw back is that there is no?

A

Xa activity

has no antidote

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21
Q

Priot to therapy of LMWH you should?

Dosing is strictly ____ based

Given ___ in ___

A

Baseline PT/INR, aPTT, CBC w/ platelet, serum creatinine

Weight based

QD or BID

Given Sub Q in the abdomen

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22
Q

AE of LMWH?

Contraindications?

A
  • Bleeding
  • Bruising
  • HIT lower risk though
  • Contraindicated if Hx of HIT or suspected HIT
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23
Q

Protamine can be used as an antidote for LMWH but it only neutralizes it by?

24
Q

LMWH is a great choice over UFH in patients that are?

25
If it is an uncomplicated DVT most patients can treat from? But the regimen must be? This reduces?
From home Strict regimen Cost saving
26
Factor Xa inhibitors?
* Fandaparinux SUB Q * Rivaroxaban * Apixaban * Edoxaban
27
Fondaparinux is indicated for?
* Prophylaxis of DVT in patients undergoing surgery * Treatment of DVT or PE when administered with warfarin
28
Fondaparunix has a ___ onset \_\_\_ elminated no ___ metabolism Long \_\_\_
rapid onset renally eliminated no liver metabolism long half life
29
AE of Fondaparinux? If major bleeding? Life threatening bleeding
* Bleeding, monitor CBC at baseline * If major bleeding then * Fresh frozen plasma * Factor concentrates * Life threatening bleed * Factor VIIa super expensive
30
Rivaroxaban and Apixaban Substrates of?
CYP3A4 and p-glycoprotein Drugs that inhibit this increase levels significantly (Ketoconazole, ritonavir, clarithromycin) Drugs that induce these may decrease levels (Carbamazepine, phenytoin, amiodarone, macrolides, diltiazem, rifampin, St johns)
31
Currently there is no ___ for Rivoraxaban and Apixaban It is also very \_\_\_
Antidote costly compared to warfarin
32
Edoxaban Indicated for? Cost compared to rivoroxaban? Avoid what?
Treatment of DVT an PE rifampin Costs less than Rivo and APixa
33
Direct Thrombin Inhibitors? What do they do?
* Bind directly to Thrombin and prevent * Formation of fibrin * positive feedback mechanism of thrombin * Platelet activation * Factor V, VIII, XI, XIII activation * Anticoag independent of AT * Able to inhibit circulation of clot bound thrombin
34
DTI drugs?
Rudin- SC injection and not indicated for HIT Argatroban- IV Dabigatran- PO
35
Advantages of using a DTI?
* Specific for thrombin * Inactivate clot bounf thrombin * No interaction with platelet factor 4 (PF4) * Have not been assoiciated with osteoporosis
36
Desirudin is indicated for?
* Prevention of DVT in elective hip surgery * SC admin * Dose every 12 hours * Renally eliminated * Monitor with aPTT
37
Argatroban? Admin? Binds to? Metabolized? No effect if? Monitor with? Approved for the treatment of?
* Binds to thrombin * IV * Liver metabolism * No effect if renally impaired * Monitor with aPTT Approved in the treatment of HIT
38
Dabigatran? Treatmetn of? Admin? Metabolized? Avoid use with? Avoid p-gp inhibitors if CrCL
* Treatment of DVT and PE * Prevention of DVT and PE in hip replacement therapy * Metabolized by liver excreted by kindeys * Avoid if CrCL \< 30 mL/min * Avoid use with P-gp inducers * 50 mL/min
39
Dabigatran antidote?
Idarucizumab IV infusion or bolus
40
DTIs AE If major bleeding give?
* Bleeding is the most common side effect * No antidate expect for Dabigatran * Major bleeding give * FFP * Factor concetrates * Prothrombin complex concentrates * Recombinant factor VIIa
41
Warfarin is the ___ anticoagulant Indicated for?
Oral anticoagulant Prevention and treatment of VTE
42
Warfarin is a very effective drug but?
* Has a narrow therapeutic window * Frequent dose admin * Patient monitoring * DIs * Food interactions
43
Warfarin \_\_\_\_ if clotting factor already formed \_\_\_ anticoag delayed __ to ___ days Potential for _________ state
No effect Full 7 to 15 days hypercoagulable state
44
Warfarin is highly Hepatically metabolized by?
Highly protein bound (albumin) Metabolized by CYP450 1A2, 2C9, 3A4
45
Warfarin does not follow linear kinetics Individual dose determined by?
* Patients response * Intensity of anticoagulation needed * Diet * D-D interactions * health Lots of monitoring
46
Warfarin If pt is \< 55 and healthy Start at ___ mg daily ot less if patient is?
7.5 - 10 * \>75 * CHF * Liver failure * Poor nutrition * Taking interacting meds * high risk of bleeding
47
International Normalized Ration or INR is?
* Standard practice for monitoring * INR range 2 -3 for treatmetn and prevention of VTE (target is 2.5)
48
When starting warfarin INR should be monitored every for the 1st week? Less frequent if? Ask pt about?
2-3 days * Weekly for 1-2 weeks * monthly 4 weeks * If stable INR test q 12 weeks Ask pt about adherence, vit K food, EtOH, Health
49
Warfarin if VTE then ____ overlapped with warfarin?
rapid acting anticoagulant minimum of 5 days And stable INR \>= 2 Adjust dose based on total weekly dose If dose is adjusted then wait and recheck INR
50
Major adverse effect of warfarin is? what else High INR = ? Instability and large fluctuations in INR?
Bleeding DI bleeding ICH Intensity of anticoagulant related to bleeding higher bleeding risk bleeding risk
51
Warfarin overdose can be corrected with?
Vit K if not working use FFP and Clotting factor concentrates
52
INR 4.5 - 10 INR \> 10
Hold 1-2 warfarin doses and decrease dose Hold 1-2 doses and resume at lower dose
53
Vit K Foods?
Anything green, chick peas, tea
54
Patient education of warfarin?
* Compliance is key * SE * Dietary instructions * Frequent INR monitoring * Physical activity * No prego * Take at night
55
Recommened Duration of Long term anticoagulation
56
Risk factors for bleeding while taking Anti coags
57

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