Warfarin and Other Anti-Coags (Weber) Flashcards
(90 cards)
1
Q
What does NOAC and DOAC mean?
A
NOAC: New Oral Anticoagulants
DOAC: Direct Oral Anticoagulants
**these are the same thing
2
Q
How do NOAC/DOACs work?
A
They each have a direct binding site and one mechanism of action
(they each only target one singular factor)
3
Q
What drug is a Direct Thrombin Inhibitor?
A
Dabigatran etexilate (Pradaxa)
**this is the only drug in this class
4
Q
What drugs are Factor Xa Inhibitors?
A
Rivaroxaban (Xarelto)
Apixaban (Eliquis)
Edoxaban (Savaysa)
5
Q
What is the brand name of Dabigatran?
A
Pradaxa
6
Q
What is the brand name of Rivaroxaban?
A
Xarelto
7
Q
What is the brand name of Apixaban?
A
Eliquis
8
Q
What is the brand name of Edoxaban?
A
Savaysa
9
Q
What is the generic name of Pradaxa?
A
Dabigatran
10
Q
What is the generic name of Xarelto?
A
Rivaroxaban
11
Q
What is the generic name of Eliquis?
A
Apixaban
12
Q
What is the generic name of Savaysa?
A
Edoxaban
13
Q
What is the postoperative prophylaxis dosing indication for Dabigatran?
A
Hip replacement ONLY!
14
Q
What is the postoperative prophylaxis dosing indication for Rivaroxaban?
A
Hip and Knee Replacement
15
Q
What is the postoperative prophylaxis dosing indication for Apixaban?
A
Hip and Knee Replacement
16
Q
What are the two drugs that can be used for BOTH hip and knee replacement?
A
-Rivaroxaban
-Apixaban
17
Q
What drug can ONLY be used for hip replacement?
A
Dabigatran
18
Q
Which drug should not be used when CrCl < 30mL/min for postoperative prophylaxis?
A
Rivaroxaban
19
Q
When dosing for non-valvular atrial fibrillation, which drug is the only one based on SCr levels?
A
Apixaban
20
Q
When dosing for non-valvular atrial fibrillation, which drug has considerations for age and body weight?
A
Apixaban
21
Q
When dosing for non-valvular atrial fibrillation, which drug performed worse in patients with better renal function?
A
Edoxaban
22
Q
When dosing for non-valvular atrial fibrillation, at what CrCl is the use of Edoxaban not recommended?
A
CrCl > 95 mL/min
23
Q
What is atrial fibrillation?
A
Irregular heart rhythm that increases the risk of stroke and systemic embolism (DVT or PE)
24
Q
What is the difference between “treatment” and “prophylaxis”?
A
Treatment: patient has already had a clotting event and we need to stabilize the clot, prevent it from growing, and prevent another one from forming
Prophylaxis: Patient has not had a clot but they have a very high risk for one. They are put on a drug to lower their risk.
25
When dosing for non-valvular atrial fibrillation, what is the preferred dosing frequency and why?
Anticoagulation treatment for afib is life-long. Because of this, it is better to choose the once-daily option to improve adherence
26
Which drug is not used in postoperative prophylaxis treatment (for hip or knee replacements)?
Edoxaban
27
When dosing for DVT/PE treatment, how long does the patient originally take the medications?
6 months
(0-6)
28
What is a DVT/PE?
A blood clot in the extremities or lungs
29
When dosing for DVT/PE treatment, which medications require parenteral anticoagulation before they can be started?
Dabigatran
Edoxaban
30
When dosing for DVT/PE treatment, which medications DO NOT require parenteral anticoagulation before they can be started?
Rivaroxaban
Apixaban
(load with high dose of the medication first, and then continue with maintenance dose)
31
When dosing for DVT/PE treatment, how long should parenteral anticoagulation be administered for before use of the maintenance anticoagulant?
5-10 days
32
When dosing for secondary prevention of recurrent DVT/PE, which medications can be used?
Rivaroxaban
Apixaban
33
When is dosing for secondary prevention of recurrent DVT/PE used?
-After 6 months of treatment for DVT/PE
34
How long does dosing for secondary prevention of recurrent DVT/PE last?
6 months
(months 6-12)
**could be life-long, but 6 months (for a total of 1 year of treatment) is more common
35
Who needs to receive VTE prophylaxis treatment?
Patients who are acutely ill in the hospital (bed rest)
(patients are immobile and are at an increased risk for developing a blood clot)
**prophylaxis= have not had clot yet, trying to prevent
36
What drug is used for VTE prophylaxis?
Rivaroxaban
37
What makes dosing warfarin difficult?
-Variable over time
-Variable between patients
38
What is the standard initial dose of warfarin?
5 mg po once daily
39
When we want to initially dose warfarin in healthy outpatients using the flexible dosing initiation method, how is warfarin dosed?
10mg for 2 days and then 5mg
(give them a higher dose to start and then change to normal initial dosing)
40
What patients would we consider using the flexible warfarin dosing initiation method in?
Patients who have a very low risk of bleeding
(healthy people, not old people who are frail)
41
When would we want to start patients on a lower warfarin dose than the typical 5mg?
If they have a high bleeding risk
(ex: old and frail)
42
When first starting a patient on warfarin, how long do we want to overlap the warfarin treatment with UFH/LMWH/Xa?
(unfractionated heparin, low molecular weight heparin, heparin)
At least 5 days AND until INR is therapeutic (within goal of 2-3)
43
If a patient is not at therapeutic INR, what doses of warfarin need to be adjusted?
Weekly dose
(note: warfarin is taken multiple times a week)
44
What is INR?
A number representing how long it takes your blood to clot
45
What is a normal INR for a patient not taking anticoagulants?
INR=1
46
What does a higher INR number signify?
The higher the INR gets, the higher the patient's bleeding risk is
(takes blood longer to clot)
47
What is the goal INR for the majority of patients?
2.0-3.0
48
If a patient is taking an oral anticoagulant to prevent recurrent MI (heart attack), what INR is recommended for them to have?
2.5-3.5
49
When initiating warfarin with the flexible initiation method, how often should patients have their INR monitored?
Daily through day 4, then within 3-5 days
50
When initiating warfarin using the average dosing method (5mg), how often should patients have their INR monitored?
Within 3-5 days, then within 1 week
51
After a patient is discharged from the hospital and initiated on warfarin, how soon should they have their INR monitored?
Stable: within 3-5 days
Unstable: within 1-3 days
52
During the first month of taking warfarin, how often should a patient have their INR assessed?
weekly
53
What is the overarching monitoring schedule that is used for patients taking warfarin?
When starting warfarin, check at least 1 INR in the first week
then:
When you have 2 INR in goal 1 week apart, change monitoring to every 2 weeks
then:
When you have two INR in goal that are 2 weeks apart, change monitoring to every 4 weeks (common for most patients)
54
When a patient is consistently stable on warfarin (no change in 6 months) how often do you have to monitor their INR?
every 12 weeks
55
What are the 5 D's that patients taking warfarin should be asked about to determine if they have interactions?
-Drugs (any changes)
-Diseases (any changes in medical condition and/or treatment)
-Doses (any missed doses)
-Diet (changes in diet, leafy green vegetables)
-Drink (any alcohol consumption)
56
What medications are most likely to interact with warfarin?
-Antibiotics (patient could have started and stopped therapy in-between getting their INR drawn)
-NSAIDs
-Aspirin
-"G" herbals (make you bleed)
57
If a patient misses a dose of warfarin the day they get their INR drawn will it be affected?
No, but missed doses a few days before could have a significant effect
58
What foods can affect warfarin action the most?
Green leafy vegetables (contain vitamin K)
59
What are some factors that may warrant a warfarin dose adjustment?
-Signs/Symptoms of bleeding
-Thromboembolic complications
-Prescription medication changes
-Diet
-Activity
-Alcohol Use
-Adverse effects
-OTC drug use
-Drug interaction screening
60
For patients with a goal INR of 2.0-3.0
If a patient has an INR of < 2, how would you adjust their dose of warfarin?
Increase dose by 5%-15%
61
For patients with a goal INR of 2.0-3.0
If a patient has an INR of 3.1-3.5, how would you adjust their warfarin dose?
Decrease dose by 5%-15%
62
For patients with a goal INR of 2.0-3.0
If a patient has an INR of 3.5-4, how would you adjust their warfarin dose?
Hold 0-1dose AND/OR Decrease dose by 10%-15%
63
For patients with a goal INR of 2.0-3.0
If a patient has an INR > 4, how would you adjust their warfarin dose?
Hold 0-2 doses AND/OR Decrease dose by 10%-15%
64
For patients with a goal INR of 2.5-3.5,
If a patient has an INR < 2.5, how would you adjust their warfarin dose?
Increase dose by 5%-15%
65
For patients with a goal INR of 2.5-3.5,
If a patient has an INR of 3.6-4, how would you adjust their warfarin dose?
Decrease by 5%-15%
66
For patients with a goal INR of 2.5-3.5,
If a patient has an INR of 4.1-4.5, how would you adjust their warfarin dose?
Hold 0-1 doses AND/OR Decrease dose by 10%-15%
67
For patients with a goal INR of 2.5-3.5,
If a patient has an INR > 4.5, how would you adjust their warfarin dose?
Hold 0-2 doses AND/OR Decrease dose by 10%-15%
68
What are three important considerations to know when dosing warfarin?
-You can adjust warfarin in half-tablet increments
-Always work with the warfarin tablet strength that the patient already has
-Get/keep a patient on one tablet strength unless there is absolutely no way to keep them controlled while doing so
69
If a patient is taking 5mg of warfarin every day with a weekly total dose of 35mg and goal INR of 2-3, but their INR is 3.2, how would you adjust their weekly dosing to start?
Need to decrease dose by 5-15%
(change weekly dose to 33.25-29.75)
*Best to have Mondays and Fridays be different
MON: 2.5
Tues: 5
Wed: 5
Thurs: 5
FRI: 2.5
Sat: 5
Sun: 5
Total Weekly Dose: 30mg
70
If a patient is taking warfarin with a goal INR of 2-3, but their current INR is 3.2 and they have already been switched over to Monday-Friday lower dosing for a total dose of 30mg weekly, how would you adjust their dose?
Decrease dose by 5-15%
(change weekly dose to 28.5-25.5)
*If Monday and Friday already have different dosing, the next step is to decrease dosing on Wednesday
MON: 2.5
Tues: 5
WED: 2.5
Thurs: 5
FRI: 2.5
Sat: 5
Sun: 5
Total Weekly Dose: 27.5mg
71
If a patient is taking warfarin with a goal INR of 2-3, but their current INR is 3.2 and they have already been switched over to Monday-Wednesday-Friday lower dosing for a total dose of 27.5mg weekly, how would you adjust their dose?
Need to decrease dose by 5-15%
(change weekly dose to 26.1-23.4)
*If Monday, Wednesday, and Friday already have lower dosing, the next step is to perform a flop
Mon: 5
Tues: 2.5
Wed: 5
Thurs: 2.5
Fri: 5
Sat: 2.5
Sun: 2.5
Total weekly dose: 25mg
(every day except Mon, Wed, and Fri has lowered dosing)
72
Why do we want to space out high and low doses of warfarin throughout the week?
Warfarin takes several days to reach its peak effect. Spacing out dosing throughout the week prevents peaks and valleys in warfarin effect from occurring.
73
If a patient is taking warfarin with a goal INR of 2-3, but their current INR is 1.7 and they have already been switched over to Monday-Friday HIGHER dosing for a total dose of 24 mg weekly, how would you adjust their dose?
*Need to increase dose by 5-15%
(change weekly dosing to 25.2-27.6)
*If Monday and Friday already have increased dosing, the next step is to increase the dose on Wednesday
Mon: 4.5
Tues: 3
Wed: 4.5
Thurs: 3
Fri: 4.5
Sat: 3
Sun: 3
Total Weekly Dose: 25.5
74
If a patient is taking warfarin with a goal INR of 2-3, but their current INR is 1.7 and they have already been switched over to Monday-Wednesday-Friday HIGHER dosing for a total dose of 25.5 mg weekly, how would you adjust their dose?
*Need to increase dose by 5-15%
(change weekly dose to 26.8-29.3)
*If Monday, Wednesday, and Friday already have higher dosing, the next step is to perform a flop
Mon: 3
Tues: 4.5
Wed: 3
Thurs: 4.5
Fri: 3
Sat: 4.5
Sun: 4.5
Total Weekly Dose: 27 mg
(Every day except Monday, Wednesday, and Friday has increased dosing)
75
What time of day should a patient take warfarin?
It does not matter what time of day a patient take their warfarin
-However, evening is typically preferred for convenience and monitoring
76
What is "bridging therapy"?
The therapy and procedure used for taking patients off of their warfarin if they are going to undergo a medical procedure/surgery with a risk for bleeding
77
When a patient needs bridging, how many days before their surgery should they stop warfarin?
5 days
78
When a patient is undergoing bridging therapy, how soon before the procedure should they stop receiving LMWH?
24 hours before the procedure
79
When a patient is undergoing bridging therapy, how soon before the procedure should they stop receiving UFH?
Stop IV UFH 4-6 hours before the procedure
80
After a patient undergoes surgery, how soon after the procedure should they restart warfarin?
12-24 hours after surgery
(assuming adequate hemostasis and low bleeding risk)
81
What is a "flexible dosing regimen" in relation to bridging?
In a flexible dosing regimen, after the patient has surgery they receive a higher-than-usual dose of metformin to jump start them back to normal INR levels
*this is onl
82
What is a "fixed dosing regimen" in relation to bridging?
In a fixed dosing regimen, after the patient has surgery, they are started back on their typical dosing schedule and do not receive a "jump start"
83
How soon before a procedure should aspirin be stopped?
1 week before
84
How is enoxaparin/lovenox dosing determined for metformin bridging?
1mg/kg every 12 hours
OR
1.5 mg/kg every 24 hours
85
When should enoxaparin/lovenox be started after stopping warfarin while bridging?
Start enoxaparin/lovenox the day after warfarin is stopped
--this gives the patient one day of no anticoagulant in their system to help the warfarin start to dissipate
86
How should enoxaparin/lovenox be dosed the day before a patient's surgery?
The day before surgery, give a half dose of enoxaparin (depending on what the patient was receiving) and only give the dose in the morning so that it has 24 hours to wear off before surgery
87
After a patient has surgery, how long should their enoxaparin/lovenox treatment overlap with their warfarin treatment?
-Overlap for at least 5 days until INR is therapeutic
(this is the same as when a patient is initially started on warfarin)
88
How soon after a patient has surgery should their INR be checked?
No sooner than 5 days but within a week
**This gives the warfarin time to reach therapeutic levels
**If INR is therapeutic, the enoxaparin/lovenox can be discontinued
89
What is the maximum amount of liquid that can be injected into a patient?
1 mL
90
What doses are available for enoxaparin/lovenox?
30, 40, 60, 80, 100, 120, 150
*Doses less than or equal to 100 can be adjusted in increments of 10 (these contain 1 mL liquid and 10mg of drug per 0.1mL)
*120mg and 150mg doses can be adjusted in increments of 15
(120mg = 0.8mL which means there is 15mg of drug per 0.1 mL)
(150= 1mL which means there is 15 mg of drug per 0.1 mL)
***If patient needs less that the pre-specified dose, have them waste drug by squirting it into the sink before injecting (this can only be done in 10 or 15 mg increments)
