Anticoagulation Flashcards by Megan Carnahan

What is the essential protein for clot formation?

fibrin

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What are the vitamin K dependent clotting factors?

2
7
9
10

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Which factors do injectable heparins target?

10a
2a

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Do direct oral factor 10a inhbitors cross react with heparin-induced thrombocytopenia antibodies?

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What are the 3 direct thrombin inhibitors?

Agatroban
Bivalirudin
Dabigatran

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Which is preferred for stroke prevention in atrial fibrillation and VTE treatment: DOAC or Warfarin?

DOAC

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Which is preferred in older adults: DOAC or Warfarin?

DOAC

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Which is preferred in stroke prevention with moderate-severe mitral stenosis or a mechanical heart valve: DOAC or warfarin?

Warfarin

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Which is preferred for VTE treatment when patient has triple positive antiphospholipid syndrome or a mechanical heart valve: DOAC or Warfarin?

Warfarin

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What do UFH and LMWH bind to to increase the activity of?

Antithrombin

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What are the main sites of bleeding with anticoagulation?

nose
superficial
deep
gingiva
gastrointestinal
urine

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What is the dose of UFH for VTE prophylaxis?

5000 units SC every 8-12 hours

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What is the dose of UFH for VTE treatment?

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

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What is the dose of UFH for ACS/STEMI treatment?

60 units/kg IV bolus; 12 units kg/hr infusion

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What are the contraindications for UFH or LMWH?

active bleed
history of HIT
hypersensitivity to pork

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What is the warning of UFH?

fatal medication errors; check for correct concentration

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What are the side effects of UFH?

bleeding
thrombocytopenia
HIT
hyperkalemia
osteoporosis
alopecia

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What should be monitored while on UFH?

Platelets, Hgb, Hct, apTT or antiXa level

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What is the typical aPTT therapeutic range?

0.3-0.7 units/mL

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When should an aPTT or antiXa level be drawn for UFH?

6 hours after starting and every 6 hours until therapeutic

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What is the antidote for UFH and LMWH?

protamine

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Which weight should be used for UFH or LMWH dosing?

total body weight

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What are heparin lock flushes used for?

To keep IV lines open

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What is the enoxaparin dose for VTE prophylaxis?

30mg SC every 12 hours
OR
40mg SC daily

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What is the enoxaparin dose for VTE prophylaxis if creatinine clearance is less than 30?

30mg sc daily

What is the enoxaparin dose for VTE, unstable angina, or an NSTEMI?

1mg/kg SC every 12 hours 1.5mg/kg SC daily (only inpatient VTE)

What is the enoxaparin dose for VTE, unstable angina, or an NSTEMI and creatinine clearance is less than 30?

1mg/kg SC daily

What is the enoxaparin dose for STEMI in a patient younger than 75?

30mg IV bolus + 1mg/kg SC dose, then 1mg/kg SC q12hr (max 100mg for 1st 2 SC doses only)

What is the enoxaparin dose for STEMI in a patient younger than 75 and a creatinine clearance less than 30?

30mg IV bolus + 1mg/kgSC dose, then 1mg/kg SC daily

What is the enoxaparin dose for STEMI in patients 75 or older?

0.75mg/kg SC q12hr; max 75mg for first 2 doses only

What is the enoxaparin dose for STEMI in patients 75 or older and a creatinine clearance less than 30?

1mg/kg SC daily

What is the dalteparin dose for VTE prophylaxis?

2500-5000units SC daily

What is the dalteparin dose for unstable angina/NSTEMI?

120 units/kg (max 10000) sc q12hr

What is the boxed warning for LMWH?

patients getting neuraxial anesthesia or spinal puncture → risk of hematoma and subsequent paralysis

What are the side effects of LMWH?

Bleeding anemia injection site reactions decreased platelets

What should be monitored while on LMWH?

platelets Hgb Hct Scr

When LMWH is used, which conditions warrant an antiXa level?

pregnancy renal insufficiency obesity low body weight pediatrics older adults

When LMWH is given, when should an antiXa level be obtained?

4 hours after the dose

Do HIT antibodies have cross sensitivity with LMWH?

yes

If the syringe of a LMWH has an airbubble should it be expelled?

LMWH interact with which drug classes?

anticoagulants antiplatelets herbals NSAID SSRI SNRI Fibrinolytic

Why should you not rub the administration site after enoxaparin is administered?

Bruising

What is heparin-induced thrombocytopenia

IgG reaction that increases risk of clotting/thrombosis

What are the parts of the 3 T score?

Thrombocytopenia: 50% unexplained drop Timing: 5-10 days after heparin or exposed to heparin in past 3 months Thrombosis: thrombus/skin lesions

How is heparin induced thrombocytopenia managed?

heparin is stopped, warfarin reverse with vitamin K (not restarted until platelets 150) a non heparin anticoagulant is used for HIT Fondaparinux can be used off label Bivalirduin if surgery or PCI

What is the dose of apixaban for stroke prophylaxis?

5mg PO BID

Apixaban 2.5mg BID can be given for stroke prophylaxis if 2 of 3 conditions are met?

the patient is 80 or older weighs 60kg or less has a SCr of 1.5 or more

What is the apixaban dose for DVT/PE treatment?

10mg BID for 7 days, then 5mg BID

How long until apixaban is decreased to 2.5mg BID for DVT/PE treatment?

6 months

What is the apixaban dose for DVT prophylaxis when a patient has had a knee replacement?

2.5 mg BID for 12 days

What is the apixaban dose for DVT prophylaxis when a patient has had a hip replacement?

2.5mg BID for 35 days

At which dose of rivaroxaban does it need to be taken with food?

15mg

What is the dose of rivaroxaban for nonvalvular atrial fibrillation?

20mg daily with evening meal

What is the dose of rivaroxaban for nonvalvular atrial fibrillation and a creatinine clearance 15-50?

15mg daily with evening meal

Rivaroxaban should be avoided when creatinine clearance is?

<15

What is the dose of rivaroxaban for DVT/PE treatment?

15mg BID x 21 days, then 20mg daily with food

What is the dose of rivaroxaban for DVT prophylaxis?

10mg PO daily - 12 days if knee replacement - 35 days if hip replacement

What is the rivaroxaban dose for risk reduction of major CVD events in CAD or PAD?

2.5mg BID in combination with low dose aspirin

At which creatinine clearance should edoxaban not be used?

>95

What is the edoxaban dose for VTE treatment?

Start 60mg daily after 5-10 days of parenteral anticoagulation

What is the edoxaban dose for VTE treatment if CrCl 15-50?

Start 30mg daily after 5-10 days of parenteral anticoagulation

What is the fondaparinux dose for VTE prophylaxis in a patient weighing 50 or more kg?

2.5mg SC daily

Can you give fondaparinux to a patient weighing less than 50 kg for VTE prophylaxis?

What is the fondaparinux dose for VTE treatment in a patient that weighs less than 50kg?

5mg SC daily

What is the fondaparinux dose for VTE treatment in a patient that weighs 50-100kg?

7.5mg SC daily

What is the fondaparinux dose for VTE treatment in a patient that weighs more than 100kg?

10mg SC Daily

What is the boxed warning for all Xa inhibitors?

Neuraxial anesthesisa → risk of hematomas and subsequent paralysis

What is the contraindication for direct antiXa inhibitors?

active bleeding

What are the warnings for direct antiXa inhibitors?

Not recommended with prosthetic heart valves or triple positive antiphosphoilipid syndrome avoid in patients with moderate/severe impairment

What are the side effects of direct antiXa inhibitors?

bleeding rash and increased LFTs (edoxaban)

What should be monitored while on direct Xa inhibitors?

Hgb Hct Scr LFTs

What is the antidote for apixaban or rivaroxaban?

Andexanet Alfa

Apixaban can be crushed and mixed with?

D5W or apple juice

For elective surgeries when should DOACs be discontinued?

24-72 hours before

What are the contraindications of fondaparinux?

Severe renal impairment CrCl <30 Active major bleed Bacterial endocarditis Thrombocytopenia with positive test for antiplatelet antibodies

What are the side effects of fondaparinux?

bleed anemia local injection site reactions thrombocytopenia

What should be monitored while a patient is on fondaparinux?

Platelets Hgb Hct Scr antiXa levels

Which drug classes interact with DOACs?

anitplatelets herbals NSAIDS SSRI SNRI Fibrinolytic

If a patient must get a CYP3A4 or P-gp inducer, apixaban should be?

decreased or not used if dose is 2.5mg BID

Edoxaban should be avoided with which drug?

Rifampin

Rivaroxaban should be avoided with?

cobicistat

What is the dose of dabigatran for nonvalvular atrial fibrillation stroke prophylaxis?

150mg BID

What is the dose of dabigatran for nonvalvular atrial fibrillation stroke prophylaxis and a CrCl 15-30?

75mg BID

What is the dabigatran dose for DVT/PE treatment?

150mg BID, start 5-10 days after parenteral anticoagulation

What is the dabigatran dose for DVT/PE prophylaxis following hip replacement?

110mg day 1 then 220mg day

What is the dose of agatroban for HIT?

2mcg/kg/min (max 10mcg)

What is the boxed warning with dabigatran?

neuraxail anesthesia, risk of hematomas and subsequent paralysis

What is the contraindication to dabigatran?

Mechanical prosthetic heart valve

What is the warning for dabigatran?

not recommended for triple positive antiphospholipid syndrome

What are the side effects of dabigatran?

dyspepsia gastritis like symptoms bleeding

What needs to be monitored while on dabigatran?

Hgb Hct Scr

What is the antidote to dabigatran?

Idarucizumab

Dabigatran should be dispensed in its original container and discarded how many months after opening?

Can dabigatran be given by NG tube?

How many days should dabigatran be discontinued prior to surgery?

CrCl 50 or more: 1-2 days CrCl <50: 2-5 days

What is the contraindication to agatroban and bivalirudin?

active bleed

What are the side effects of agatroban and bivalirudin?

bleeding anemia

What needs to be monitored while on agatroban or bivalirudin?

aPTT activated clotting time platelets Hgb HCt hepatic function (agatroban) renal function (bivalirudin)

Do agatroban or bivalirudin have cross reactions with HIT antibodies?

If a patient is getting agatroban, should a loading dose of warfarin be used?

Which drug should be avoided with dabigatran if CrCl <50?

Rifampin

If a patient is taking dronedarone or systemic ketoconazole what dose should dabigatran be reduced to?

75mg BID

When switching from Warfarin to Rivaroxaban wait until INR is less than?

When switching from Warfarin to Edoxaban wait until INR is?

2.5 or less

When switching from Warfarin to Apixaban or Dabigatran wait until INR is less than?

When switching from Xa inhibitors to Warfarin what should be done?

Stop the Xa inhibitor, start parenteral anticoagulation and warfarin at the next dose

How many days should warfarin be started before stopping dabigatran?

1-3 days before

How does Warfarin work?

inhibits VKORC1 to decrease production of clotting factors

What is the outpatient dose of warfarin?

10mg or less daily for first 2 days, then adjust dose per INR

Warfarin is started at 5mg or less in which conditions?

Older Malnourished Drug Interactions Liver Disease Heart Failure Risk of Bleeding

What is the boxed warning for warfarin?

major/fatal bleed

What is the contraindication for warfarin?

Pregnancy

What are the warnings for warfarin?

Tissue necrosis/gangrenee HIT Purple toe syndrome Polmorphisms 2* or 3* of VKORC1 may induce bleeding risk

What are the side effects of warfarin?

bleed, bruise, skin necrosis

INR should be monitored with warfarin after 2-3 doses, and then chronically how often?

Every 4-12 weeks

What is the goal INR for most indications?

2-3

What is the goal INR if a patient has a mechanical mitral valve, two mechanical heart valves, or mechancail aortic valve?

2.5-3.5

What is the antidote for warfarin?

Vitamin K

S-Warfarin targets which enzyme?

CYP2C9

R-Warfarin targets which enzyme?

CYP3A4

Warfarin + which drugs will decrease INR?

phenytoin carbamazepine phenobarbital rifampin St. Johns Wort

Warfarin + which drugs increase INR

amiodarone azole antifungals capecitabine cimetidine fluvastatin fluvoxamine metronidazole tamoxifen tigecycline bactrim zafirlukast

Can warfarin and tamoxifen be used together?

When starting amiodarone, the warfarin dose should be?

Decreased by 30-50%

What dose an alcohol binge do to INR?

increase

How long do tube feeds need held for warfarin?

1 hour before and after administration

What are examples of foods high in vitamin K?

Spinach Broccoli Brussel sprouts Collard greens Kale Turnip greens Green onion

What color is 1mg of warfarin?

pink

What color is 2mg of warfarin?

lavender

What color is 2.5mg of warfarin?

green

What color is 3mg of warfarin?

brown/tan

What color is 4mg of warfarin?

blue

What color is 5mg of warfarin?

peach

What color is 6mg of warfarin?

teal

What color is 7.5mg of warfarin?

yellow

What color is 10mg of warfarin?

white

How many mg of protamine sulfate reverses 100 units of heparin?

1mg

Since UFH has a short half life, the amount of protamine given should reverse the amount of UFH given in the last?

2-2.5 hours

What is the max dose of protamine?

50mg

How many mg of protamine per 1mg of enoxaparin given in last 8 hours?

How much protamine should be given if LMWH was given more than 8 hours ago?

0.5mg per 1mg enoxaparin

How much protamine should be given for dalteparin reversal?

1mg per 100 antiXa units

What is the boxed warning for andexanet alfa?

Thromboembolic risk Ischemic events cardiac arrest sudden death

What are the side effects for andexanet alfa?

injection site reaction UTI pneumonia antibody development

What is the dose of idarucizumab?

5g IV as 2 separate doses no more than 15min apart

What are the warnings for idarucizumab?

thromboembolic risks risk of serious adverse reactions due to sorbitol excipient

What are the side effects for idarucizumab?

headache constipation hypersensitivity reaction

What is the dose of Vitamin K for warfarin reversal?

1-10mg PO or IV

If vitamin K is given IV what is the minimum amount that should be given?

50mL

What is the boxed warning for vitamin K?

Hypersensitivity Reaction

What are the side effects of Vitamin K?

anaphylaxis flushing rash dizzy

Does vitamin K require light protection?

yes

What is the boxed warning for Four Factor Prothrombin Complex?

arterial and venous thromboembolic complications

What is the contraindications for Four Factor Prothrombin Complex?

HIT, disseminated intravascular coagulation, IgA deficiency with antibodies to IGa

What is the warning for Four Factor Prothrombin complex?

Made from human blood (incr risk of transmitting infectious agents)

What are the side effects of four factor prothrombin complex?

Headache NVD asthenia hypotension hypokalemia thrombotic events

Three factor prothrombin complex should be given with?

Fresh frozen plasma

What is the warning for three factor prothrombin complex?

has factors 2,9, 10 only, made from human blood (incr risk of infection)

What are the side effects of three factor prothrombin complex?

chills fever flushing nausea headache risk of thrombosis

What does three factor prothrombin complex need to be given with?

antihistamine Vitamin K

What is the dose of factor Viia recombinant?

10-20mcg/kg IV bolus

What is the boxed warning for Factor VIIa Recombinant?

serious thrombotic events

If INR is above therapeutic range but less than 4.5 without bleed...

reduce/skip warfarin dose, monitor inr Restart inr when therapeutic

If INR 4.5-10 without bleeding...

Hold 1-2 doses of warfarin Oral Vit K can be used in urgent surgery is needed

If INR >10 without bleeding....

Hold warfarin Give oral vitamin K

If there is a major bleed on warfarin...

Hold warfarain Give Vit K infusion 5-10mg via slow IV injection and four factor PCC

Warfarin should be stopped how many days before surgery?

Which components of the CHADVASC score are worth 2 points?

age 75 or more prior stroke/TIA/thromboembolism

What are the components of the chad vasc score?

CHF HTN Age 75 or more Diabetes Prior Stroke/TIA/Thromboembolism Vascular Disease Age 65-74 Sex: Female

If a male scores a 1 or female scores a 2 on chadvasc what should be done?

Consider oral anticoagulation

If a male scores a 2 or female scores a 3 on chadvasc what should be done?

Oral anticoagulation recommended. Non Vitamin K oral anticoagulant recommended over warfarin

What are the components of the HASBLED risk?

HTN Abnormal Liver/Kidney Function Prior Stroke Bleeding Tendency/Predisposition Labile INR if on warfarin Elderly (older than 65) Drugs/Excess alchol

Which 2 components of the HAS BLED Score can be worth 2 points?

abnormal liver/kidney function drugs/excess alcohol

Which anticoagulant is preferred in pregnancy?

LMWH

Anticoagulation Flashcards

(174 cards)