NAPLEX > Anticoagulation > Flashcards

Anticoagulation Flashcards

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1
Q

prevent blood clots from forming, do not break down clots

used to treat VTE

used in ACS to prevent cardioembolic stroke

A

anticoagulants

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2
Q

3 factors that can lead to activation of coagulation (Virchows triad)

A

blood vessel injury, blood stasis, pro-thrombotic conditions

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3
Q

DTIs (argatroban, bivalrudin, dabigatran) act on

A

thrombin, IIa

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4
Q

inhibitors of factor Xa include

A

direct - rivaroxaban, apixaban, edoxaban

indirect- fondaparinux

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5
Q

which factors are targeted by heparins

A

Xa, IIa

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6
Q

which factors are targeted by warfarin

A

VII, IX, X, II

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7
Q

DOACs include

A

direct Xa inhibitors and DTIs

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8
Q

vitamin K antagonist that blocks use of K for activation of factors _ _ _ _?

A

II, VII, IX, X
warfarin

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9
Q

warfarin has a narrow therapeutic index and requires monitoring of

A

INR

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10
Q

when is warfarin preferred over DOAC for stroke prevention in AF

A

mod-to-sev mitral stenosis or a mechanical heart valve

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11
Q

when is warfarin preferred over DOAC for VTE treatment

A

triple positive antiphospholipid syndrome or a mechanical heart valve

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12
Q

Beers List consideration for DOACs

A

rivaroxaban has increased bleeding risk and should be avoided for long term use of AF/VTE in older adults

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13
Q

endogenous anticoagulant that inactivates thrombus and factor Xa

A

antithrombin (AT)

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14
Q

which anticoagulants bind antithrombin to increase its activity

A

UFH, LWMHs, fondaparinux

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15
Q

which heparin inhibits factor Xa more greatly

A

LMWH»_space; UFH

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16
Q

anticoagulants are high alert medications since they

A

have risk of significant bleeding

check for acute Hg drop

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17
Q

binds antithrombin and inactivates thrombin (IIa) and Xa preventing conversion of fibrinogen to fibrin

A

UFH

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18
Q

dose of UFH used for VTE prophylaxis

A

5000 units SC Q8-12H

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19
Q

dose of UFH used for treatment of VTE

A

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

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20
Q

dose of UFH used for treatment of ACS/NSTEMI

A

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

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21
Q

what weight is used for UFH dosing

A

total body weight

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22
Q

warnings and contraindication of UFH

A

CI - active bleed
warning - fatal med errors, verify correct concentration

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23
Q

AEs of UFH

A

bleeding, thrombocytopenia, HIT, hyperkalemia

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24
Q

how to monitor UFH?
what is the therapeutic range of aPTT?

A

target aPTT or anti-Xa levels - check 6 hrs after initiation then every 6 hours until therapeutic

aPTT therapeutic range is 1.5-2.5x control

monitoring not required for SC dosing

PLT, H&H

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25
when using heparin, what PLT change may indicate HIT?
decrease >50%
26
antidote of UFH
protamine
27
UFH continue IV infusions are common due to
short half life
28
heparin lock flushes are only used to
keep IV lines open caution of fatal med errors, especially in neonates
29
binds to antithrombin and inactivates Xa >> IIa
LMWHs
30
LMWHs are also known as
enoxaparin (Lovenox)
31
what weight is used for LMWH dosing
total body weight
32
dosing of LMWH used for VTE prophylaxis ? renal?
30mg SQ Q12H or 40mg SC daily crcl <30 - 30mg SQ daily
33
dosing of LMWH used for treatment of VTE and UA/NSTEMI? renal?
1 mg/kg SC Q12H or 1.5 mg/kg SQ daily (inpatient VTE treatment only) crcl<30 - 1mg/kg SQ daily
34
dosing of LMWH used for STEMI treatment in age <75
30mg IV bolus plus a 1mg/kg SC dose
35
dosing of LMWH used for STEMI in age >75? renal?
no bolus needed crcl<30 - 1mg/kg SC daily
36
BBW LMWH
risk of hematomas and subsequent paralysis in patients receiving neuraxial anesthesia (epidural, spinal)
37
LMWH contraindications
history of HIT, active major bleed
38
AEs of LMWH
bleeding, anemia, injection site rxn, dec platelets
39
monitoring for LMWH when is anti-Xa recommended and how
PLT, H&H, SCr anti-Xa in pregnancy, renal insufficiency, obesity, low body weight peak levels 4 hours post SC dose
40
LMWH antidote
protamine
41
storage and admin points for LMWH
do not expel air bubbles, store and room temp
42
do HIT antibodies have cross sensitivity with LMWH
yes
43
immune mediated IgG drug reaction where antibodies are formed and platelet activation occurs; prothrombotic state
HIT
44
4 Ts score assessed for HIT
Thrombocytopenia (unexplained drop >50% in PLT) Timing (5-10 days) Thrombosis oTher causes
45
initial management of HIT
stop all forms of heparin and LMWH alt anticoagulant needed (nonheparin)- argatroban d/c warfarin if on it and reverse with vitamin K
46
when can warfarin be started/restarted after HIT
PLT recover to >150,000
47
alternate option for HIT off label? if cardiac surgery or PCI is needed?
off label- fondaparinux surgery- bivalrudin
48
3 oral direct Xa inhibitors
apixaban, rivaroxaban, edoxaban
49
brand name apixaban
eliquis
50
brand name rivaroxaban
xarelto
51
dosing of eliquis for nonvalvular AF? reduced?
5mg BID 2.5mg BID if criteria met
52
2 of 3 of these criteria must be met for reduced dosing of eliquis
age >80 BW <60kg SCr >1.5
53
dosing of eliquis for treatment of VTE
initial 10mg BID x7 days then 5mg BID
54
BBW of DOACs
risk of hematomas and subsequent paralysis in patients receiving neuraxial anesthesia (epidural, spinal)
55
edoxaban BBW - has reduced efficacy when
CrCl >95 - do not use
56
DOAC contraindication
active pathological bleeding
57
DOAC warning - not recommended with
prosthetic heart valves or triple positive antiphospholipid syndrome
58
AE of DOACs
bleeding
59
antidote of apixaban and rivaroxaban
andexanet alfa (ANdexxa)
60
how to take rivaroxaban
dose >15 mg take with food "with evening meal"
61
what to do if miss a dose of rivaroxaban taking 15mg BID? 10/15/20mg daily?
15mg BID - take 2 at once 10/15/20mg QD - take immediately same day
62
dose of rivaroxaban for VTE treatment
initial 15mg BID x21 days then 20mg daily with food
63
avoid use of rivaroxaban if crcl
crcl <15
64
when can edoxaban be started for VTE treatment
started after 5-10 days of parenteral anticoagulation
65
BBW fondaparinux
risk of hematomas and subsequent paralysis in patients receiving neuraxial anesthesia (epidural, spinal)
66
fondaparinux contraindication
severe renal impairment (crcl <30)
67
AE of fondaparinux
bleeding
68
apixaban DDI
avoid with strong dual inducers of P-gp and CYP3A4
69
rivaroxaban DDI
avoid with drugs that are combined P-gp and strong CYP3A4 inducers or inhibitors
70
agents that directly inhibit thrombin (IIa)? which are PO vs injectable
DTIs PO -dabigatran inject- argatroban, bivalrudin
71
brand name of dabigatran
Pradaxa
72
brand name of bivalrudin
Angiomax
73
what to do if miss dabigatran dose
take immediately unless within 6 hours of next dose
74
when can dabigatran be started for VTE treatment to reduce recurrence
after 5-10 days of parenteral anticoagulation
75
BBW dabigatran
risk of hematomas and subsequent paralysis in patients receiving neuraxial anesthesia (epidural, spinal)
76
contraindication dabigatran
mechanical prosthetic heart valve
77
AEs of dabigatran
dyspepsia, gastritis-like sx, bleeding (GI)
78
monitoring for dabigatran
not required
79
antidote of dabigatran
idarucizumab (Praxbind)
80
dispensing and admin of dabigatran
dispense in original container, discard 4 mos after opening swallow whole, do not admin in NG tubes
81
when are injectable DTIs used for PCI
in patients at risk for or with HIT does not cross react with HIT Ab
82
AE of argatroban and bivalrudin
bleeding
83
antidote of argatroban and bivalrudin
NONE
84
convert from warfarin to another anticoagulant based on INR READ
Rivaroxaban INR <3 Edoxaban INR <2.5 Apixaban INR <2 Dabigatran INR <2
85
how to switch from apixa/rivarox/edox to warfarin
stop Xa inhibitor - start parenteral anticoagulant and warfarin at next dose edoxaban- refer to package label
86
how to switch from dabigatran to warfarin
start warfarin 1-3 days before stopping dabigatran
87
competitively inhibits VKORC1 which decreases production of factors II, VII, IX, and X and protein C & S
warfarin
88
brand name of warfarin
jantoven
89
missed dose of warfarin
do not double dose
90
initial dose of warfarin in healthy outpatients
<=10 mg daily first 2 days then adjust per INR
91
when is an initial lower dose <5mg of warfarin needed
older adults, malnourished, drugs that can inc warfarin levels, liver disease, HF, high bleed risk
92
warfarin contraindication
pregnancy (except with mechanical heart valves)
93
warfarin warnings
tissue necrosis/gangrene HIT purple toe syndrome presence of CYP2C9*2 or *3 alleles and/or polymorphism of VKORC1 may increase bleed risk
94
AEs of warfarin
bleeding/bruising, skin necrosis
95
goal INR
most: 2-3 mech mitral valve, two mech heart valves: 2.5-3.5
96
warfarin antidote
vitamin K
97
why do drugs that interact on 2C9 have a greater effect on warfarin
racemic mix of R & S isomers -- S is more potent and metabolized by 2C9
98
PK DDIs with warfarin as a 2C9 substrate
cyp inducers can dec INR cyp inhibitors can inc INR
99
what to do with warfarin when starting amiodarone
dec warfarin dose by 30-50%
100
PD DDIs withb warfarin
drugs that inc bleeding risk and drugs that inc clot risk
101
which natural supplements can increase bleed risk with warfarin
5Gs - garlic, ginger, ginkgo, ginseng, glucosamine dong quai, omega 3s at high doses, vit E, willow bark (salicylate)
102
which natural product can decrease warfarin effectiveness
SJW
103
consumption of ___ can affect INR
alcohol
104
foods high in vitamin K that patients should stay consistent with in their diet
spinach, broccoli, brussel sprouts, collard greens, kale
105
how can tube feeds affect warfarin absorption
proteins decrease warfarin absorption
106
how is warfarin initiated for VTE treatment
start while receiving parenteral anticoagulation and continue both for at least 5 days and until INR is >= 2 for at least 24 hours
107
is bridging recommended for patients with stable INR who present with one low INR
no
108
how often is INR checked in those with consistently stable INRs
12 weeks
109
warfarin tablet colors Please Let Greg Brown Bring Peaches To Your Wedding
Pink 1 mg Lavender 2mg Green 2.5mg Brown 3mg Blue 4mg Peach 5mg Teal 6mg Yellow 7.5mg White 10mg
110
for IV UFH reverse, 1mg of protamine will reverse ___ units of heparin. max dose of protamine?
~100 units of heparin Max 50mg protamine
111
how much UFH should be reversed with protamine based on half life
amount of heparin given last 2 - 2.5 hours
112
for LMWH reversal, 1mg of protamine is used per ___ mg of enoxaparin
1mg enoxaparin
113
brand name of vitamin K or phytonadione
Mephyton
114
how is vitamin K admin
PO or IV
115
BBW and AE of vitamin K
BBW- hypersensitivity AE- anaphylaxis
116
vitamin K requires what for admin
light protection
117
SC and IM vitamin K are not recommended due to __ and ___.
SC- variable absorption IM- risk of hematoma
118
brand name of four factor prothrombin complex concentrate
Kcentra, Balfaxar
119
FFPC (Kcentra) is used to reverse what factors
factors II, VII, IX, X, Protein C & S
120
FFPC (kcentra) should be administered with
vitamin K
121
three factor prothrombin complex concentrate contains which factors
II, IX, X
122
brand name of factor VIIa recombinant
NovoSeven RT
123
preferred form and dose of vitamin K for warfarin reversal without major bleed
PO 2.5-5mg doses
124
when is IV vitamin K used. whats the risk and how to avoid?
serious bleed anaphylaxis risk - slow infusion
125
what to do if INR is above therapeutic but <4.5 without bleeding
reduce/skip warfarin dose and monitor
126
what to do if INR 4.5-10 without bleeding
hold 1-2 doses, vitamin K not recommended
127
what to do if INR >10 without bleeding
oral vitamin K
128
what to do if major bleeding on warfarin
give vit K IV and 4 factor PCC
129
what to do with warfarin before a major surgery? if mech heart valve, AF, VTE at high risk of thromboembolism?
5 days before surgery if those things- bridge therapy with LMWH/UFH and d/c 24 hrs before surgery low risk for thromboembolism do not need bridging
130
modifiable risk factors for VTE
acute medical illness, immobility, medications, obesity (BMI >30), pregnancy/postpartum, recent surgery/major trauma
131
non-modifiable risk factors for VTE
increasing age, cancer or chemo, previous VTE, inherited or acquired thrombophilia, certain disease states (HF, resp failure)
132
non-drug VTE prevention options? long distance travelers?
intermittent pneumatic compression (IPC) devices or graduated compression stockings travel- frequent ambulation, calf muscle exercises, using graduated compression
133
how long are VTEs treated?
3 months extended phase with low dose can be used
134
which medication classes are contraindicated with history of or current VTE
estrogen containing medications, SERMS
135
what is preferred for VTE treatment in patients without cancer
dabigatran, DOACs >> warfarin
136
what is preferred for VTE treatment in patients with cancer
DOACs >> other orals and LMWH
137
duration of anticoagulation required if undergoing cardioversion and AF >48 hours
3 weeks prior to and 4 weeks after cardioversion
138
duration of anticoagulation required if undergoing cardioversion and AF <48 hours
start at presentation and continue full anticoagulation for at least 4 weeks
139
for patients who remain in AF, the need for chronic anticoagulation is based on
stroke risk CHA2DS2-VASc estimation
140
patients with mechanical heart valve have highest risk for stroke/clot and should receive? what is not approved?
warfarin only not approved- Xa inhibitors and DTIs
141
components of the CHA2DS2-VASc scoring
C - CHF 1 H - HTN 1 A2 - age >75 2 D - diabetes S2 - prior stroke/TIA, thromboembolism 2 V - vascular disease 1 A - age 65-74 1 Sc - sex category female 1
142
CHA2DS2-VASc scores to indicate anticoagulation
0m, 1f - no anticoag 1m, 2f - consider >=2m, >=3f - DOAC
143
HAS-BLED scoring determines
risk of bleeding based on number of risk factors
144
what is preferred for anticoagulation in pregnancy and how to monitor
LMWH anti-Xa levels to monitor
145
what is not recommended and contraindicated in pregnancy
not recommended- DTIs and DOACs teratogen- warfarin
146
how to inject enoxparin
right or left side of abdomen, at least 2 inches from the belly button do not expel air bubbles unless advised to do so do not rub injection site
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