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Flashcards in VTE Prophylaxis Deck (57):
1

Prophylaxis goal?

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

2

Non pharm treatment Therapy for VTE

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

3

Pharmacologic Prophylaxis

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

4

Standard dosing for LMWH ?

Regardless of weight

5

Risk Level

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6

  • What are the goals for VTE treatment?

  • 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

7

UFH is from?

Does what to clots?

From procine stomach or bovine lung

Does not dissove clot but prevents growth 

Binds to AT

neutralizes Thrombin factors Xa IX, Xia, XIIa

8

UFH is administered?

Non specific binding site so?

IV and Sub Q

Sub Q onset is 1-2 hours

Poor bioavailability 

9

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

What type of dosing is there?

therapeutic dose within 24 hours 

Weight base

Standard dose

VTE chart

10

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

Activated partial thromboplastin time (aPTT) 

11

Normal therapeutic range for aPTT?

___ to ___ the control aPTT value

28-42 seconds

1.5 to 2.5 

12

Baseline aPTT is done?

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

Takes 6 hours to reach steady state 

13

Adverse effects of UFH/

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

14

HIT

  • 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

 

15

UFH antidote?

Protamine

16

UFH is ok to using in ___ patients

if patient is ____

Contraindication?

Pregnant 

Can breastfeed

Contraindication is Hx of HIT

17

LMWH

Binds to Xa not much to do with thrombin 

18

Advantages of LMWH?

  • 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

 

19

LMWH products

Parin, Parin, Parain

 

Dalteparin

Enoxaparin

Tinzaparain

20

LMWH has much greater effect on ___ 

but a draw back is that there is no?

Xa activity

has no antidote 

21

Priot to therapy of LMWH you should?

Dosing is strictly ____ based

Given ___ in ___ 

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

 

Weight based

QD or BID

Given Sub Q in the abdomen 

22

AE of LMWH?

Contraindications?

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

23

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

60%

24

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

pregnant 

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 

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56

Risk factors for bleeding while taking Anti coags

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57