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Anticoagulation C/P
Anticoagulation - clinical pearl
| Question | Answer |
|---|---|
| What anticoagulant is safe for pregnancy | Enoxaparin (Lovenox) |
| TRUE or FALSE: warfarin is safe for pregnancy | FALSE |
| List of teratogenic medications | Warfarin ACE inhibitors Isotretinoin Lithium Methotrexate NSAIDs Phenytoin Topiramate Valproate |
| What anticoagulant inhibits on both Xa, IIa | - Heparin (ratio 1:1) - Enoxaparin (Lovenox, ratio 2:1 ) |
| What factor does warfarin inhibit? | factor VII, IX, X and II |
| What are Direct Factor Xa Inhibitors (PO)? | (1) Rivaro - Xa - ban (2) Api - Xa - ban (3) Edo - Xa - ban |
| TRUE or FALSE: adjust heparin dose if CrCl < 30 mL/min | FALSE, No dose adjustment for heparin in pt w renal dysfunction |
| Heparins VTE Ppx Dosing | 5,000 units SC Q8-12H |
| Enoxaparin (Lovenox) VTE Ppx Dosing | - 30 mg SC Q12H or 40 mg SC QD - If CrCl < 30 mL/min: 30 mg SC QD |
| Heparins VTE treatment dose | Bolus 80 units/kg IV, then infuse 18 units/kg/hr IV |
| Heparins ACS (STEMI, NSTEMI, UA) treatment dose | Bolus 60 units/kg IV, then infuse 12 units/kg/hr IV |
| Heparin treatment dosing for VTE vs ACS memorize | - VTE: 80 -18 - ACS: 60 -12 - Bolus for both heart and non-heart |
| What body weight used to calculate dosing of heparin and Enoxaparin | - For Ppx, dosing regardless to body weight - For treatment, use total body weight |
| Enoxaparin (Lovenox) treatment dosing for VTE and and UA/NSTEMI | - 1 mg/kg SC Q12H - If CrCl < 30 mL/min: dosing every 24H |
| Enoxaparin (Lovenox) treatment dosing for STEMI | for pt < 75 yrs Bolus 30 mg IV, then immediately start 1 mg/kg SC Q12H, 1.5mg/kg QD - CrCl < 30 mL/min: 1mg Q24H |
| Heparin-induced thrombocytopenia | Platelets reduction > 50% within 5-10 days after starting heparin D/C & start an IV DTI (eg, Argatroban or Bivalirudin) |
| What are Direct Thrombin Inhibitors (DTIs) | DTIs inhibit IIa: Dabigatran (PO), Argatroban (IV), Bivalirudin (IV) IV DTIs: used in cath lab / HIT |
| BOXED WARNING for enoxaparin | Hematomas/paralysis in patients receiving neuraxial anesthesia (punch the spine) |
| Therapeutic monitoring for heparin | aPTT, 6 hours after infusion starts or rate changes |
| heparin Antidote | Protamine (Dose ratio for Heparin 1: 100, max 50mg, Lovenox 1:1, then 0.5:1 if needed) |
| Therapeutic monitoring for Enoxaparin (Lovenox) | NOT require, OR Anti-Xa PRN four hour post dose peak level, for: pregnant, renal dysfunction, elderly, or extreme body weight (obese or very low body weight) |
| Enoxaparin Counseling points | • the air bubble in the syringe should not be expelled • Skin pinched to create a fold • Needle inserted / removed at 90-degree angle • patients should avoid rubbing the site of injection • rotate the injection sites to minimize bruising |
| Apixaban (Eliquis) dosing for Afib | 5 mg PO BID, OR half dose if 2.5 mg PO BID if 2 of the following: age ≥80 years, weight ≤ 60 kg, SCr ≥ 1.5 mg/dL |
| Apixaban (Eliquis) dosing for VTE | Loading dose: 10 mg PO BID x 7 days Maintenance dose: 5 mg PO BID |
| Rivaroxaban (Xarelto) dosing for Afib | - 20 mg PO daily - CrCl 15 - 50 mL/min: 15 mg PO daily - CrCl 15 mL/min: 15 mg QD (per manufacturer) |
| Rivaroxaban (Xarelto) dosing for VTE | - LD: 15 mg PO BID x 21 days - MD: 20 mg PO daily. After 6mo: 10mg QD - CrCl 15-30 mL/min: caution - CrCl < 15 mL/min: AVOID |
| What Rivaroxaban (Xarelto) requires taking with foods? | Doses ≥ 15 mg should be taken with dinner |
| What DOACs require taking with food | Rivaroxaban (Xarelto) with doses ≥ 15 mg |
| Andexxa (andexanet alfa) | Antidote for both: Apixaban (Eliquis) & Rivaroxaban (Xarelto) |
| Dabigatran (Pradaxa) dosing for VTE | - MUST bridging w parenteral anticoagulant 5-10 days - Then: 150 mg PO BID - CrCl < 30 mL/min: AVOID |
| What DOACs require keeping in original container | Dabigatran (Pradaxa), discard 4 months after opening (capsule) or 6 months (pelletes) |
| Praxbind (idarucizumab) is | Antidote for Pradaxa |
| what CrCl value that do not use Edoxaban as its efficacy reduced? | • AF only: do not use if CrCI > 95 mL/min |
| What DOACs need parenteral anticoagulant bridging for VTE | Dabigatran (Pradaxa) & Edoxaban: 5-10 days warfafin: min 5 days and until the INR is ≥ 2 for at least 24 hours. |
| Oral anticoagulant dosing for VTE treatment - bridging days | 5 - 7 (apixatran) - 21 (rivaroxaban) |
| Edoxaban dosing for Afib | • 60 mg PO daily • CrCI < 15 or > 95 mL/min: avoid use • CrCI 15-50 mL/min: 30 mg PO daily |
| what anticoagulants used in patients with prosthetic heart valves | warfarin |
| what anticoagulants have box warning of neuraxial anesthesia | DOACs, heparin / lovenox |
| Warfarin dosing | Healthy out pt: 10 mg for the first 2 doses, then adjust to INR goal. Use a starting dose of ≤ 5 mg for • HF • Liver disease • Malnutrition • Elderly • High risk of bleeding (including from drugs that increase warfarin levels) |
| Warfarin tablet colors | Please - Let - Greg - Brown - Bring - Peaches - To - Your - Wedding Pink (1mg) - Lavender (2mg) - Green (2.5 mg) - Brown/Tan (3 mg) - Blue (4 mg) - Peach (5 mg) - Teal (6 mg) - Yellow (7.5 mg) - White (10 mg) 1 - 2 - 2.5 - 3 - 4 - 5 - 6 - 7.5 - 10 |
| Warfarin Antidotes | vitamin K (phytonadione), prothrombin complex concentrate (PCC) |
| warfarin INR goals | • 2-3 for most indications • 2.5-3.5 for mechanical mitral valve OR mechanical aortic valve + another indication for anticoagulation |
| Managing warfarin bleeding risk based on INR | • INR < 4.5 w/o bleeding: Reduce or skip warfarin dose • INR 4.5-10 w/o bleeding: Hold 1-2 doses of warfarin • INR > 10 w/o bleeding: Hold warfarin, vit K 2.5-5 mg PO • Major bleed: Hold warfarin, vit K 5-10 mg (slow IV) AND 4-factor PCC |
| CYP2C9 DDI which increase INR Warfarin "MAT" Drugs | M - metronidazole and macrolides (Clarithromycin, Erithromyein) A - amiodarone and azole antifungals T - trimethoprim/sulfamethoxazole |
| Warfarin concurrent use w Amiodarone | dose reduction 30-50% |
| Major CYP2C9 inducers reduce INR | Remember: Review Patient Profiles and Counsel Soon • Rifampin • Phenytoin • Phenobarbital • Carbamazepine • St. John's wort |
| Warfarin Additive bleeding risk w/o increase in INR | • NSAIDs, aspirin (and other antiplatelet drugs), SSRIs and SNRIs • Natural products: "the 5 G's": Garlic, ginger, ginkgo biloba, ginseng, glucosamine |
| Only indication which warfarin is indicated for pregnant women | warfarin is teratogenic, considered to be contraindicated in pregnant patients. The exception is pregnant patients with a mechanical heart valve |
| What anticogulants are prefered for DVT of leg or PE WITHOUT cancer | Dabigatran, rivaroxaban, apixaban, or edoxaban are recommended over warfarin for the duration of treatment |
| What anticogulants are prefered for DVT of leg or PE WITH cancer | • Rivaroxaban, apixaban, or edoxaban are recommended over LMWH for initiation AND treatment phases of therapy • Dabigatran is NOT preferred |
| How long anticoagulants are indicated for DVT | 3 months- provoked DVT ( prolonged treatment need or unprovoked DVT.) |
| CHA2DS2-VASc Scores (2 for: age ≥ 75 years and stroke) | 1 C - congestive heart failure 1 H - hypertension 2 A - age ≥ 75 years 1 D - diabetes 2 S - stroke 1 V - vascular disease 1 A - age 65-74 years 1 Sc - sex category (1 for female) |
| CHA2DS2-VASc Scores for indication of anticoagulants | • consider if score is 1 for male and 2 for female • indicate anticoagulant if score is 2 for male and 3 for female |
| From warfarin to another oral DOACs, stop warfarin and convert to (READ 3-2.5-2) | • Rivaroxaban when INR is < 3 • Edoxaban when INR is ≤ 2.5 • Apixaban when INR is < 2 • Dabigatran when INR is < 2 |
| Modifiable risk factors for VTE | • Acute medical illness • Immobility • Medications: ESAs (Epoetin, Darbepoetin), Estrogen-containing, SERMs (Tamoxifen and Raloxifene) • BMI ≥ 30 • Pregnancy & postpartum • Recent surgery or trauma |
| Nonmodifiable risk factors for VTE | • Increasing age • Cancer • Heart failure • Known thrombophilia • Antiphospholipid syndrome • Antithrombin deficiency • Factor V Leiden mutation • Protein C or S deficiency • Previous VTE • Respiratory failure |
| Symptoms of Life-threatening bleeding due to anticoagulants | Hypotension, tachycardia, bleeding, low hemoglobin/hematocrit |
| what dose of vit K and route if INR > 10 w None or minimal bleeding | • Hold warfarin • Administer 2.5-5 mg oral vitamin K • Resume warfarin at a lower dose when INR is therapeutic |
| what dose of vit K and route if pt experiences Serious or life threatening | • Hold warfarin • Administer IV vitamin K 5-10 mg & 4-PCC* |
| DDI between levofloxacin and warfarin | increase bleeding risk / INR (Alteration of intestinal flora: quinolones, tetracyclines) |
| TRUE or FALSE: pt on anticoagulant can take advil or Doan's for pain control | FALSE, Tylenol is the safe option |
| Vit K (phytonadione) 10 mg inject intravenously, what is the SE? | Hypersensitivity reaction |
| Can vit K be administrated via SC? | NO, Unpredictable absorption |
| what is the Parenteral route for phytonadione for bleeding due to warfarin | • Avoid IM route due to the risk of hematoma • SC Unpredictable absorption • IV. To mimimize the risk of a hypersensitivity reaction, the drug must be diluted in a minimum of 50 mL and administered at a slow rate, not to exceed 1 milligram per minute. |
| Patients with factor VIII deficiency are at risk of clotting or bleeding? | Bleeding risk Factor VIII deficiency is a form of hemophilia (cannot properly form a blood clot and are at high risk of bleeding) |
| Patients with factor III and V deficiency are at risk of clotting or bleeding? | Clotting risk |
| What anticoagulants are prefer in pt w cancer | Oral factor Xa inhibitors and LMWHs (after Xa inhibitors or pts w certain GI malignancies) |
| INR goal for pt w mitral Mechanical valves | 2.5 - 3.5 |
| INR goal of 2.5-3.5 if | • Mechanical aortic valve with at least 1 risk factor • Mechanical mitral valve • Two mechanical heart valves |
| INR and albumin relation | Because warfarin is highly protein-bound, free drug levels increase in the presence of hypoalbuminemia, thereby increasing INR and bleeding risk |
| Low albumin | High INR and bleeding risk (high free drug level) |
| pt on anticoagulants w findings that indicate bleeding include | • ecchymosis - Xuất huyết dưới da • epistaxis - Chảy máu cam • hemoptysis - Ho ra máu • menorrhagia - Rong kinh |
| Pharmacogenomic testing for warfarin incl | CYP2C9*2 & *3, VKORC1 (CYP2C9*2/*3 alleles are associated with an increased risk of bleeding and need for a lower maintenance dose) |
| Protamine dose as an reversal for heparin IV | 1 : 100 (dose calculated for the last 2 hrs) No more than 50 mg of protamine should be given in one dose. |
| after Cardioversion, when will be the soonest to d/c anticoagulants | minimum 4 weeks (prior cardioversion, pt is on 3 wks of anticoagulants) |
| Foods cause reduction of INR | • Brussel sprouts • Kale • Spinach |
| Rivaroxaban (Xarelto) 15 mg PO BID - missing dose | • Take a missed dose as soon as possible • Two tablets may be taken at once if it is close to the next dose |
| Rivaroxaban (Xarelto) PPx for DVT and PE | - 10 mg QD for 12 Ds (knee replacement) - 10 mg QD for 35 Ds (hip replacement) - 10 mg QD for 31 - 39 Ds (critical ill) - CrCl 15 - 30 mL/min: caution - CrCl < 15 mL/min: AVOID |
| Rivaroxaban (Xarelto) reduction risk for major CVD events in CAD / PAD | - 2.5 mg BID (+ low dose aspirin) |
| Heparin monitoring | - aPTT (normal: 20 - 40'). Therapeutic: 45 - 70' |
| Prothrombin Time: PT | - Affected by warfarin |
| Heparin dosing based on aPTT (Rule 4-2-0-2-3 : minus 4 - minus 2 - zero - plus 2 - plus 3) | - < 35: bolus 80, increase 4U/kg/h - 35 - 45 ': bolus 40, increase 2U/kg/h - 71 - 90': decrease 2U/kg/h - > 90': hold 1h, decrease 3U/kg/h |
| HIT | - Platelet drops > 50% within 5-10 days - Stop heparin, use argatroban - D/c warfarin, vit K (resume warfarin if platelet > 150,000 w leading - Avoid Heparin, Lovenox for life - Document heparin allergy in chart |
| Agartroban and INR | - False INR if agartroban + warfarin |
| Off label for HIT | - Foundaparinus - Apixaban - Rivaroxaban |
| HIT w urgent cardiac surgery or PCI | Bivalurudin |
| Preferred anticoagulant for most pregnant women | - Enoxaparin - Dalteparin (Fragmin) |
| What anticoagulants are not used if PORK allergy | - Heparin - LMWH |
| Meds increase INR "A Clever Fox Met Two Zebras" | Inhibitors: - A: Amiodaron, Azole - C: Capecitabine, cimetidine - F: Fluvastatin, fluvoxamin - M: Metronidazole - T: TMP/SMX, Tygecycline, Tamoxifen - Z: Zafirlukas Reduce warfarin 30-50% if starting amiodarone |
| Meds decrease INR "RiP COPS" | Inducers R = Rifampin P = Phenytoin C = Carbamazepine O = Oxcarbazepine P = Phenobarbital S = St. John's wort |
| Tamoxifen + warfarin | AVOID |
| Ventricular rate control in patients with Afib can be managed by: BAND | - Beta-blockers - Amiodarone - Non-DHP CCB (verapamil, or diltiazem) - Digoxin |
| DAPT duration | - Bare Metal Stent: 1 mo, up to 1 yr - Drug Eluting Stent: 6-12 mos, then ASA - DES high bleeding risk: 1-3 mos, then P2Y12 up 1 yr, then either P2Y12 or ASA - DES high ischemic: increase DAPT duration - NOT interrupted for surgery unless emergency |
| How many day should clopidogrel hold / discontinue prior elective surgery | 5 Ds, but MUST complete minimum DAPT duration of uninterrupted |
| Dabigatran (Pradaxa) dosing for Afib | - 150 mg BID - CrCl 15 - 30mL/min: 75 mg BID - CrCl < 15 mL/min: AVOID |
| Dabigatran (Pradaxa) PPx DVT/PE for hip replacement surgery | - D1: 110 mg - D2+: 220 mg - CrCl < 30 mL/min: AVOID |
| Arixtra (fondaparinux) indications | - DVT prophylaxis (> 50 kg): 2.5 mg SQ DQ - DVT treatment: < 50 kg - 5mg, 50-100 kg: 7.5mg, > 100kg - 10mg - Can be given to patients with a history of HIT (lacks cross-reactivity with HIT antibodies) - CrCl 30-50mL/min: caution, < 30: CI |
| Meds for intermittent claudication? | Cilostazol |
| Lovenox dose for DVT PPx | - Knee/Hip: 30 mg Q12H - Hip: Alternative dose 40 mg QD - Abdominal surgery: 40 mg QD |
| Lovenox monitoring | - Platelet - SCr (dose adj if CrCl < 30 mL/min) - Hgb, Hct |
| Lovenox monitoring: aPTT or antiXa PNR for 4 special pts? | - AntiXa |
| Both unfractionated heparin and LMWs can cause hyperkalemia | Yes (by suppressing aldosterone synthesis) |
| Based on ACCP guidelines, how many days after starting warfarin should INR levels be checked? | 3-5 days |
| What foods have high in vitamin K (decrease INR) "A Big Brown Cow Gives Kids Lots of Strong Tasty Vegetables" - Consistent dietary intake of foods high in vitamin K | A = Alfalfa B = Broccoli, Brussels sprouts B = (Brown) = Cabbage, Cauliflower C = (Cow) = Cabbage/Cauliflower reminder G = Green tea K = Kale L = Lettuce S = Spinach T = Turnip greens V = Vegetables (Watercress, Asparagus) |
| American Ginseng and INR | - DECREASE - Other Gs and Vit E: increase |
| Waste bins should warfarin be discarded in | Black |
| Pradaxa SEs | - Dyspepsia - Gastritis-like symptoms - Bleeding (incl GI) |
| Clopidogrel and grapefruit/grapefruit | AVOID or minimize grapefruit/grapefruit juice with clopidogrel due to reduced antiplatelet effect |
| Increase the chance of bleeding when on Effient (Prasugrel) | - < 60kg - > 75 yrs - NSAIDs - SSRI, SNRI (Check pls) |
| Concurrent administration of voriconazole (an inhibitor) with Plavix (prodrug) | INCREASE risk of thrombosis (not bleedina). |
| Chest pain and can NOT chew ASA | - Rectal suppository dose of 600 mg. |
| ASA MoA | - Irreversibly inhibits COX-1 and 2 - IRReversibly inhibits formation of prostaglandin derivative, thromboxane A2 |
| Lovenox STEMI dose for > 75 yrs | - 0.75mg/kg Q12H, no bolus, max 75mg for first 2 doses |
Created by:
dao.vo11017