Pre VTE

Question 1

Virchow’s Triad

1. ___ state - abnormalities of clotting componnets
2. ___ injury - abnormality of surfaces in contact with blood flow
3. circulatory ___ - abnormalities in blood flow

Answer 1

1) hypercoaguable
2) endothelial
3) stasis

Question 2

Activators of Coagulation

Answer 2

• vWF
• tissue factor
• VIIa
• Xa
• XIIa
• thrombin (IIa)
• XIIIa
• tissue plasminogen activator (t-PA)

Question 3

Inhibitors of Coagulation

Answer 3

• heparin
• thrombomodulin
• antithrombin
• protein C and S
• tissue factor pathway inhibitor
• plasminogen activator inhibitor -1 (PAI-1)

Question 4

DVT Risk Factors

• • age > ___ years
• family history
• heart failure
• immobilization > ___ days
• malignancy
• myocardial nifarction
• obesity
• orthopedic injury
• oral contraceptive/estrogen use
• paralysis
• post operative state within ___ months
• pregnancy
• prior DVT
• varicose veins

Answer 4

• 40
• 10
• 3

Question 5

Which heparin product has a higher risk of HIT?
LMWH or UFH?

Answer 5

UFH

Question 6

UFH

• rapid, ___ anticoagulant
• variable dose response = need for ___ monitoring
• aPTT: activated Partial Thromboplastic Time = time it takes to form a ___
• goal: ___ - ___ time control

Adverse Effects:
- bleeding
- thrombocytopenia

Answer 6

• parenteral
• aPPT
• clot
• 1.5-2.5

Question 7

UFH dosing - weight based

IV bolus: ___ units/kg
infusion: ___ units/kg/hr

Monitoring:
- aPTT at baseline
- ___ hours after dose or with each dosage change (for first ___ hours)
- check daily after first day, unless out of range

Answer 7

• 80
• 18
• 6, 24

Question 8

HAT

Heparin Associated Thrombocytopenia
- aka HIT ___
- ___ mediated
- mild decrease in platelets, but still greater than ___ mm3
- occurs around ___ - ___ hours after administration of heparin
- transient
- do not need to d/c heparin

Answer 8

• type I
• non-immune
• 100,000
• 48-72

Question 9

HIT

Heparin Induced Thrombocytopenia
- ___ mediated
- ___ complications
- occur between: ___- ___ days
- can occur up to ___ days after stopping therapy
- platelets drop > ___% from baseline OR < _____ mm3

Answer 9

• immune
• thrombotic
• 7-14
• 9
• 50, 100,000

Question 10

HIT Management

• stop all ___ products
• give alternate anticoagulant ( ___ , ___ , ___ , or ____ )
• do not give ___ infusions
• do not give ___ until platelet count is > ___
• evaluate for thrombosis

Answer 10

• heparin
• lepirudin, argatroban, bivalirudin, fondaparinux
• platelet
• warfarin, 150, 000

Question 11

LMWH advantages vs UFH

• ___ protein binding
• ___ dose response: fixed or ___ based dosing possible, ___ not required
• ___ plasma t1/2
• smaller molecule: improved ___ absorption
• less effect of ___ and endothelium: reduced incidence of ___

Answer 11

• reduced
• predictable, weight, monitoring
• longer
• SQ
• platelets, HIT

Question 12

LMWH dosing - enoxaparin (Lovenox)

Prophylaxis
- ___ mg SQ q12h (surgery)
- ___ mg SQ daily (medical)

Treatment:
- ___ mg/kg SQ q12h
- ___ mg/kg SQ daily

Renal Dysfunction
- ___ mg SQ daily (prophylaxis)
- ___ mg/kg SQ daily (treatment)

Answer 12

• 30
• 40
• 1
• 1.5
• 30
• 1

Question 13

LMWH dosing - dalteparin (Fragmin)

Prophylaxis
- ___ - ___ units SQ daily

Treatment
- ___ units/kg SQ daily for ___ days, then ___ units SQ daily

treatment is also used for VTE patients with cancer

Answer 13

• 2500-5000
• 200, 30, 150

Question 14

Monitoring Anti Xa Levels

consider for children, severe kindey failure, obesity, long courses, pregnancy

• Twice daily dosing: ___ - ___ units/mL, obtained ___ hours post dose
• once daily dosing: ___ - ___ units/mL, obtained as ___
• can. consider peak of ___ - ___ units/mL obtained ___ hours post dose

Routine monitoring not ___

Answer 14

• 0.6-1.0, 4
• 0.1-0.3, trough
• 1-2, 4
• recommended

Question 15

Injectable Factor Xa Inhibitor

Fondaparinux
- uses: prophylaxis following ___ , ___ , ___ replacement, or ___ surgery
- treatment of ___ or ___

prophylaxis dosing: ___ mg SQ once daily (following ___ , ___ , or ___ surgery)

treatment:
- < 50 kg: ___ mg SQ once daily
- 50-100 kg: ___ mg SQ once daily
- > 100 kg: ___ mg SQ once daily

Answer 15

• THA, TKA, hip, abdominal
• DVTT, PE
• 2.5 mg, hip, knee, abdominal
• 5
• 7.5
• 10

Question 16

Fondaparinux Considerations

• do not use if there is ___ dysfunction (CrCl < ___ mL/min)
• do not use for prophylaxis with body weight less than ___ kg
• can be used in ___
• no routine monitoring; can monitor ___ levels (similar to LMWH)
• pregnancy category ___ (Safe)

Answer 16

• renal, 30
• 50
• HIT
• anti-Xa
• B

Question 17

IV Direct Thrombin Inhibitors

Lepirudin
- Use: ___
- Goal aPTT: 1.5-2.5 normal
- reduce dose CrCl < ___ mL/min

Bivalirudin (Angiomax)
- Use: ___ , UFH alternative during ___

Argatroban
- Use: ___
- elevates ___, overlap with warfarin until INR >/= 4
- caution in ___ dysfunction

Answer 17

• HIT, 60
• HIT, PCI
• HIT, INR, hepatic

Question 18

NOACs/DOACs

Direct Thrombin Inhibitor (1)

Factor Xa Inhibitors (4)

Answer 18

Direct Thrombin Inhibitor
- dabigatran (Pradaxa)

Factor Xa Inhibitors
- rivaroxaban (Xarelto)
- apixaban (Eliquis)
- edoxaban (Savaysa)
- betrixaban (Bevyxxa)

Question 19

NOAC approved indications

Dabigatran (3)
- postoperative prophylaxis ( ___ )
- non-valvular ___
- ___ / ___ Treatment

Answer 19

• hip
• A-fib
• DVT/PE

Question 20

NOAC approved indications

Rivaroxaban (5)
- ___ prophylaxis
- non-valvular ___
- ___ / ___ treatment
- secondary prevention of recurrent ___ / ___
- ___ prophylaxis

everything

Answer 20

• postoperative
• A-fib
• DVT/PE
• DVT/PE
• VTE

Question 21

NOAC approved indications

Apixaban (4)
- ___ prophylaxis
- non-valvular ___
- ___ / ___ treatment
- secondary prevention of recurrent ___ / ___

Answer 21

• postoperative
• A-fib
• DVT/PE
• DVT/PE

Question 22

NOAC approved indications

Edoxaban (2)
- non-valvular ___
- ___ / ___ treatment

Answer 22

• A-fib
• DVT/PE

Question 23

NOAC approved indications

Betrixaban
- ___ prophylaxis

Answer 23

VTE

Question 24

Which enantiomer of warfarin is more potent? R or S?

Answer 24

S

Question 25

# Warfarin Drug Interactions Increase INR

Answer 25

erythromycin metronidazole fluconazole amiodarone ciprofloxacin bactrim anabolic steroids isoniazid propafenone

Question 26

# Warfarin Drug Interactions Decrease INR

Answer 26

Rifampin cholestyramine carbamazepine

Question 27

# Alcohol and Warfarin Acute ingestion of alcohol will ___ INR

Answer 27

increase | increase anticoagulant effect of warfarin by inhibiting its metabolism

Question 28

# Alcohol and Warfarin Chronic alcohol use without liver damage will ___ INR

Answer 28

decrease | enhances metabolism by inducing hepatic enzymes, decreases effect of war

Question 29

# Alcohol and Warfarin Chronic alcohol use with liver damage will ___ INR

Answer 29

increase | due to lack of hepatic enzymes, increased anticoagulant effect

Question 30

# Warfarin Strengths available in 9 strengths

Answer 30

- 1 - 2 - 2.5 - 3 - 4 - 5 - 6 - 7.5 - 10

Question 31

# MOA of warfarin - does not effect ___ factors or previously formed ___ - inhibits enzymes responsible for cyclic conversion of vitamin ___ - inhibit synthesis of vitamin K dependent clotting factors: ___ , ___ , ___ , and ___ - protein __ and ___

Answer 31

- circulating, thrombi - K - II, VII, IX, X - C, S

Question 32

# Warfarin PK/PD and half-lives - anticoagulant effect within ___ hours - peak effects ___ - ___ - duration of action from a single dose: ___ - ___ days ___ metabolized S: CYP ___ , ___ , ___ R: CYP ___ and ___

Answer 32

- 24 - 72-96 - 2-5 Hepatically - 2C9, 2C19, 2C18 - 1A2, 3A4

Question 33

# Warfarin Genetic Variances CYP ___ ___* and ___* decrease S-warfarin clearance - occurs in 1/3 ___ pts - need to ___ the dose - potential ___ bleeding risk and ___ time to reach goal - 9, 5, 8, and 11 are ore common in ___ and ___

Answer 33

2C9 2* and 3* - white - lower - increased, longer - asians, AA

Question 34

Warfarin Genetic Variances VKORC1 - ___ A and ___ T - decreases VKOR production - ___ A increases warfarin ___ ; requires lower dose ( ___ ) - 1639 ___ - increased warfarin ___ ; requires higher dose ( ___ )

Answer 34

1639, 1173 1639, sensitivity; asians - G, resistance, AA

Question 35

# Antiplatelets - medication classes 1) COX- ___ inhibitors; Example: ___ 2) ___ receptor inhibitors 3) GP ___ / ___ receptor blockers 4) ___ - 3 inhibitors; Example: ___ 5) ___ acivated receptor inhibitors

Answer 35

- 1, aspirin - ADP - IIb/IIIa - phosphodiesterase, dipyridamole - protease

Question 36

# Antiplatelet use in VTE limited role in VTE - ___ : consideration for CHA2DS2-VASc score 1 - ___ : consider concomitant use with warfarin with prosthetic heart valve - concomitant use with ___ and increased risk of bleeding - adjunct role to ___ - significant role in ACS and other atrial ischemic vascular disorders like ___ and CVA

Answer 36

- ASA - dipyridamole - anticoagulants - thrombolytics - PAD

Question 37

# Bleeding Management/Antidotes Consider: - activated ___

Answer 37

- charcoal - dabigatran - tranexamic - protamine - idarucizumab - andexanet

Question 38

# idarucizumab (Praxbind) MOA: direct binder to ___ (higher affinity than ___ to ___) - Dose: ___ g IV (2 separate ___ g doses no more than 15 min apart) - ADR: delirium, headache, hypokalemia, constipation, pneumonia fever Monitoring Schedule: - baseline ___ , repeat in 2 hours, every ___ hours until normal

Answer 38

dabigatran dabigatran, thrombin - 5 g, 2.5 g - aPTT, 12

Question 39

# Andexanet Alfa (Andexxa) MOA: binds and sequesters ___ inhibitors ( ___ and ___ ) - ADR: local site infusion reaction, DVT, schemix stroke, AMI, PE, UTI, or pneumonia - no specific monitoring parameters

Answer 39

FXa rivaroxaban and apixaban

Question 40

# Warfarin Bleeding Management dependent on __ and presence of bleeding Vit K - PO: ___ mg tabs - Parenteral: do not exceed ___ mg/min ( anaphylaxis) Fresh Frozen Plasma (FFP) - ___ - ___ mL/kg Prothrombin Complex Concentrate (PCC) - ___ IU/kg (check INR before, 30-60 min after)

Answer 40

INR 5 mg, 1mg/min 10-15 mL/kg 30 IU/kg

Question 41

# Warfarin: Bleeding Management - if INR 4.5-10 + no bleeding: avoid ___ - if INR > 10 + no evidence of bleeding: PO ___ - major bleeding while on warfarin: ___ preferred over ___ . May add ___ 5-10 mg as well

Answer 41

- vit K - vit K - PCC, FFP, vit K

Question 42

# Warfarin Reversal - rapid reversal (10-15 min, complete) - ___ - fast (partial) - ___ - prompt (4-6 hours) - IV ___ - slow (within 24 hours) - PO ___ - very slow (3-5 days) - omit ___

Answer 42

- PCC - FFP - vit K - vit K - warfarin

Question 43

# VTE Prophylaxis - without prophylaxis: VTE incidence ___ - ___ % in medical patients - without prophylaxis: VTE incidense ___ - ___ % in surgical patients

Answer 43

- 5-15% - 40-80%

Question 44

# VTE Prophylaxis VTE Prophylaxis Options (4)

Answer 44

- UFH - LMWH - Factor Xa inhibitors - Vit K antagonists

Question 45

# VTE Risk Stratification - Moderate risk General Surgery : ___ , ___ , and ___ ( ___ ) recommended, continue prophylaxis up to 28 days after hospital discharge Acutely ill medical patients: ___ , ___ , ____ , ___ , and ___ , all appropriate - ___ : 31-39 days total treatment - ___ : 35-42 days total treatment

Answer 45

- UFH, LMWH, Factor Xa inhibitors (fondaparinux) - UFH, LMWH, fondaparinux, rivaroxaban, betrixaban - rivaroxaban - betrixaban

Question 46

# VTE Risk Stratification - High risk Orthopedic Surgery (TKA, THA) (7) - continue longer than ___ - ___ days postop (consider up to ___ days)

Answer 46

- LMWH - UFH - Fondaparinux - rivaroxaban - apixaban - dabigatran (hip) - vitamin K antagonist 10-14 days, 35 days

Question 47

# High Bleeding risk ___ prophylaxis preferred - intermittent pneumatic compression devices - venous foot ___ - ___ compression stockings

Answer 47

mechanical - pumps - graduated

Question 48

What does CHA2DS2-VASc stand for?

Answer 48

- Congestive HF (1) - HTN (1) - Age >/= 75 YO (2) - diabetes (1) - Stroke/TIA (2) - Vascular Disease (1) - Age 65-74 years (1) - Female (1) | vascular disease = prior MI, peripheral artery disease, or aortic plaque

Question 49

# CHA2DS2- VASc and HAS-BLED - anticoagulant therapy reduces risk of stroke and all cause mortality - used to guide the use of anticoagulants in patients with ___ - CHA2DS2-VASc: risk factors for ___ or systemic ___ - HAS-BLED: risk factors for ___

Answer 49

- A-fib - stroke, VTE - bleeding | A-fib increases risk of stroke/systemic VTE by 5x

Question 50

# What does HAS-BLED stand for? - Hypertension (SBP > ___ mmHg) (1) - abnormal ___ and ___ function (1 or 2) - ___ - bleeding tendency/predisposition (1) - labile ___ (if on warfarin) (1) - Age > ___ YO - drugs or EtOH (1 or 2)

Answer 50

- 160 - renal, liver - stroke - INRs - 65

Question 51

# Score Interpretations CHA2DS2-VASc; start anticoagulant is score greater or equal to ___ HAS-BLED; patient has high risk of bleeding if score greater than or equal to ___ - if any medication is used, oral ___ is preferred over ___

Answer 51

- 2 - 3 - anticoagulation, antiplatelet