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RxPrep
VTE (Oral meds)
| Question | Answer |
|---|---|
| Which oral anticoagulants are direct factor Xa inhibitors? | Apixaban, rivaroxaban, edoxaban |
| Which oral anticoagulant is a direct thrombin inhibitor? | Dabigatran |
| Which oral anticoagulants are considered DOACs? | Apixaban, rivaroxaban, edoxaban, dabigatran |
| Preferred oral anticoagulants for most VTE patients? | DOACs |
| Which oral anticoagulants are preferred in cancer-associated VTE per the book? | Dabigatran and the oral factor Xa inhibitors |
| Which oral anticoagulants are used for long-term VTE prevention after initial treatment? | Apixaban and rivaroxaban at reduced doses |
| Which oral anticoagulant(s) is not preferred in pregnancy? | Warfarin also DOACs (due to lack of studies) |
| Generic eliquis | Apixaban |
| What is the generic for Xarelto? | Rivaroxaban |
| What is the generic for Savaysa? | Edoxaban |
| What is the generic for Pradaxa? | Dabigatran |
| How long is a VTE usually treated? | 3 months minimum |
| How long is provoked VTE treated? | 3 months |
| For UNprovoked VTE, what may be recommended after initial treatment? | Continue anticoagulation if recurrence prevention is desired and no contraindication |
| Which oral anticoagulants are used for extended VTE prevention after 6 months? | Apixaban and rivaroxaban |
| Which oral anticoagulant also requires initial parenteral anticoagulation before use for VTE? | Dabigatran and edoxaban both need 5+ days of parenteral anticoagulation for VTE (before starting these 2 drugs) |
| Which oral Xa inhibitors can be started directly for VTE treatment without prior parenteral anticoagulation? | Apixaban and rivaroxaban |
| Which oral anticoagulant is preferred for mechanical heart valves? | Warfarin |
| What clotting factors are reduced by warfarin? | II, VII, IX, X |
| What natural anticoagulants are also reduced by warfarin? | Protein C and S (increases risk of clot for the first few days of treatment, needs bridging) |
| Why can warfarin initially increase clotting risk? | Protein C declines early |
| What are the 5 Gs of warfarin counseling? | Green leafy vegetables, Genetics, Goal INR, Give same time daily, Generic/color changes |
| Goal INR for most warfarin patients? | 2-3 (2.5-3.5 for heart valve) |
| Which drug can cause purple toe syndrome or skin necrosis? | Warfarin |
| Which warfarin isomer is more potent? | S-isomer |
| How does alcohol affect warfarin/INR? | Drinking causes short terms increases in INR, long term can decrease INR |
| Which foods are high in vitamin K? | Spinach, broccoli, brussels sprouts, kale, collard greens, turnip greens, swiss chard, parsley, cabbage, lettuce, asparagus, green onion, some teas (basically green stuff) |
| How often does INR need to monitored for warfarin? | Every 4-12 |
| How is warfarin metabolized? | S-warfarin: 2C9 R-warfarin 1A2 and 3A4 |
| Which drugs are we most concerned about for increasing warfarin levels? | Amiodarone, fluconazole, metronidazole, TMP-SMX, macrolides, azoles |
| Which common drugs decrease warfarin effect/INR by inducing metabolism? | Rifampin, carbamazepine, phenobarbital, phenytoin |
| Which other drug classes increase bleeding risk with anticoagulants in general? | NSAIDs, antiplatelets, SSRIs, SNRIs, fibrinolytics |
| Which protein-bound drugs can displace warfarin and increase effect? | Phenytoin, valproic acid |
| How do antibiotics affect warfarin beyond CYP effects? | Can reduce vitamin K-producing gut flora and increase INR |
| How should enteral tube feeds be timed with warfarin? | Hold 1 hour before and 1 hour after warfarin |
| What class is dabigatran? | Direct thrombin inhibitor |
| What is dabigatran’s major boxed warning? | Increased risk of thrombotic events if prematurely discontinued; spinal/epidural hematoma risk |
| What is the major common ADR of dabigatran? | Dyspepsia / gastritis-like symptoms |
| Can dabigatran be put in a pill box? | No, keep in original bottle or blister package |
| What is the missed-dose rule for dabigatran? | If the next dose is less than 6 hours away, skip the missed dose |
| Which antidote reverses dabigatran? | Idarucizumab (Praxbind) |
| What is dabigatran’s major interaction pathway? | It is a p-gp substrate |
| What renal cutoff makes dabigatran inappropriate for VTE prophylaxis per the book? | CrCl ≤30 mL/min: avoid |
| What renal cutoff for dabigatran in NVAF (non-valvular afib)? | CrCl <15 mL/min: avoid |
| Which strong P-gp inhibitor can increase dabigatran? | Ketoconazole and dronedarone |
| When switching from warfarin to dabigatran, what INR is needed? | INR <2 |
| Which drugs are oral direct factor Xa inhibitors? | Apixaban, rivaroxaban, edoxaban |
| Box warning for all DOACs? | Increased risk of thrombotic events if prematurely discontinued; spinal/epidural hematoma risk |
| Which oral factor Xa inhibitors are substrates of both CYP3A4 and P-gp? | Apixaban and rivaroxaban |
| Which antidote reverses apixaban and rivaroxaban? | Andexanet alfa (Andexxa) |
| How is rivaroxaban started for TREATMENT of DVT/PE? | 15 mg BID with food for 21 days, then 20 mg daily with food |
| What dose is used for extended VTE PREVENTION with rivaroxaban? | 10 mg daily after at least 6 months of initial treatment |
| Which drug must be taken with a full glass of water? | Dabigatran, to reduce GI upset |
| Which drug must be taken with food? | Rivaroxaban at 15-20mg doses |
| What is the standard treatment dose of edoxaban for DVT/PE? | 60 mg daily |
| What dose reductions are listed for edoxaban? | 30 mg daily if CrCl < 50 mL/min, body weight ≤60 kg, or certain P-gp inhibitors |
| CI with warfarin? | Pregnancy |
| Usual starting dose of warfarin? | 2-5mg daily for 1-2 days |
| What overlap requirement is listed for acute VTE for bridging warfarin? | At least 5 days and until INR is therapeutic for 24+ hours |
| Antidote for warfarin? | Vitamin K, (phytonadione) |
| Dosing for vitamin K in warfarin reversal? | usually 2.5-5mg if there is not major bleeding, given by mouth unless major bleed. |
| Can vitamin K be given SC or IM for warfarin reversal? | NO, SC injections are too slow and IM can cause hematomas |
| Why is IV vitamin K only used in urgent situations for reversal? | Risk of anaphylactoid reactions |
| When converting from warfarin to apixaban, what INR is required? | INR < 2 |
| When converting from warfarin to dabigatran, what INR is required? | INR < 2 |
| When converting from warfarin to edoxaban, what INR is required? | INR ≤2.5 |
| When converting from warfarin to rivaroxaban, what INR is required? | INR <3 |
| Which oral anticoagulant must be kept in the original bottle/blister and not repackaged? | Dabigratran |
| Which oral anticoagulant must be taken with food at higher doses? | Rivaroxaban 15 mg and 20 mg |
| Which oral anticoagulant can cause dyspepsia and gastritis-like symptoms? | Dabigratran |
| Which oral anticoagulant class has black box warnings about spinal/epidural hematoma? | All DOACs |
| For BID drugs like apixaban and rivaroxaban, what happens if a patient misses the first dose of the day? | May double up for the second daily dose if needed |
| What is preferred for life-threatening warfarin bleeding? | 4-factor PCC plus vitamin K |
Created by:
cdaughtry