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RxPrep
Anticoagulation (dosing/indications)
| Question | Answer |
|---|---|
| UFH prophylaxis dosing for VTE? | 5,000 units SC Q8–12H |
| UFH treatment dosing for VTE? | 80 units/kg IV bolus, then 18 units/kg/hr infusion |
| UFH treatment dosing for ACS/STEMI? | 60 units/kg IV bolus, then 12 units/kg/hr infusion |
| What body weight is used for UFH dosing? | Total body weight (TBW) |
| Should UFH be given IM? | No — avoid IM due to hematoma risk |
| UFH CIs? | Uncontrolled active bleeding, severe thrombocytopenia, history of HIT |
| UFH non-bleeding ADRs? | Thrombocytopenia, HIT, hyperkalemia, osteoporosis with long-term use, alopecia |
| What preservative issue exists with some UFH products? | Some contain benzyl alcohol; avoid in neonates/infants/pregnancy/breastfeeding |
| What platelet change suggests possible HIT? | >50% drop from baseline |
| What is UFH’s antidote? | Protamine |
| Are aPTT/anti-Xa levels required for SC prophylactic UFH? | No, only for active tx of VTE or ACS/STEMI |
| What lab is commonly used to titrate IV UFH? What is the alternative? | aPTT alternative: Anti-Xa level |
| When should aPTT be checked after starting IV UFH? How often do we keep checking? | 6 hours after initiation, then every 6 hours until therapeutic |
| After therapeutic, how often should aPTT be checked? | q24 hours |
| When else should aPTT be checked? | After any dosage change |
| Target therapeutic aPTT range for UFH? | 1.5-2.5x control |
| Target therapeutic anti-Xa range for UFH? | Usually 0.3–0.7 units/mL |
| What are the 2 main LMWH products used? | Lovenox (Enoxaparin) Dalteparin/Fragmin |
| Enoxaparin VTE prophylaxis dose? | 30 mg SC Q12H or 40 mg SC daily |
| Enoxaparin VTE prophylaxis dose if CrCl <30 mL/min? | 30 mg SC daily |
| Enoxaparin treatment dose for VTE / UA / NSTEMI? | 1 mg/kg SC Q12H or 1.5 mg/kg SC daily |
| When is enoxaparin 1.5 mg/kg daily used? | Inpatient VTE treatment ONLY |
| Enoxaparin TREATMENT dose if CrCl <30 mL/min? | 1 mg/kg SC DAILY (not q12h) |
| Enoxaparin STEMI dose if age <75? | 30 mg IV bolus + 1 mg/kg SC, then 1 mg/kg SC Q12H *max of 100mg/dose for first 2 doses* |
| Enoxaparin STEMI dose if age ≥75? | 0.75 mg/kg SC Q12H; *no IV bolus **Max of 75mg/dose for first 2 doses** |
| Enoxaparin STEMI dose if CrCl <30? | 1 mg/kg SC daily; no bolus |
| What weight is used for enoxaparin dosing? | TBW |
| Dalteparin VTE prophylaxis dose? | 2,500–5,000 units SC daily |
| Dalteparin UA/NSTEMI treatment dose? | 120 units/kg SC Q12H; max 10,000 units |
| LMWH boxed warning? | Spinal/epidural hematoma with neuraxial anesthesia or spinal puncture |
| LMWH contraindications? | History of HIT, active major bleeding, hypersensitivity to pork |
| Is routine efficacy monitoring required for LMWH? | No, generally not required (may be used in pregnancy, renal insufficiency, obese/underweight patients, peds, or geriatrics |
| If LMWH monitoring is needed, what level is used? | Anti-Xa level, not aPTT |
| When should LMWH anti-Xa peak be drawn? | 4 hours after SC dose |
| Who may need LMWH anti-Xa monitoring? | Pregnancy, renal insufficiency, obesity, low body weight, pediatrics, older adults |
| What is our reversal agent for LMWHs? | Protamine |
| Counseling for LMWH? | Do not expel air bubble, do not give IM (expelling air bubble can cause loss of drug) |
| Is LMWH safe in patients with history of HIT? | NO, cross reactivity can occur |
| Fondaparinux brand name? | Arixtra |
| What is the appropriate use of Fondaparinux in VTE prophylaxis? | if weight ≥50 kg: 2.5 mg SC daily if weight <50kg: contraindicated |
| How is fondaparinux dosed in VTE treatment? | <50kg: 5mg SC daily 50-100kg: 7.5mg SC daily >100kg: 10mg SC daily |
| What is the renal dosing for fondaparinux? | CrCl 30-50: caution CrCl <30: contraindicated |
| How do the risks of Fondaparinux compare with UFH and LWMH? | Both and cause spinal hematoma, thrombocytopenia, injection reactions, and bleeds |
| Regular monitoring for Fondaparinux? | Generally not required, if needed check anti-Xa 3 hours after SC dose |
| What is the antidote for Fonda? | None |
| What drug class is Fonda? | Injectable INDIRECT factor Xa inhibitor |
| Which anticoagulant can cause falsely high INR readings? | Argotraban |
| Which injectable anticoagulants would be ideal for patients who have had HIT? | INjectable direct thrombin inhibitors (Argatroban and Bivalrudin) |
| HIT is caused by? | IgG drug reaction to UFH or LMWH |
| Onset time for HIT? | Usually 5-10 days, but can occur within hours if the patient had heparin in the last 3 months |
| What anticoagulant should be used for patients who have HIT, why? | Argatroban or bivalrubin, anticoag is still needed since HIT is prothrombotic despite the drop in platelets |
| What should be done if a warfarin patients develops HIT? | Stop warfarin and reverse with vitamin K (since warfarin can cause hypercoagulability |
| When can we restart warfarin after HIT? | after platelets recover to >150k, but 5mg mg max for the intital dose |
| When can warfarin be used in pregnancy? | Only if patient has a mechanical heart valve with high risk for thromboembolism |
Created by:
cdaughtry