Anti-Coagulation

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Author:
HUSOP2014
ID:
272377
Filename:
Anti-Coagulation
Updated:
2014-04-29 11:49:42
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HUSOP NAPLEX 2014
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Description:
NAPLEX anticoagulation review
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  1. What are the monitoring parameters of the following?
    Heparin:
    LMWH:
    Fondaparinux:
    Rivaroxaban:
    Apixaban:
    Argatroban:
    Bivalirudin:
    Dabigatran:
    Warfarin:
    • Heparin: aPTT, Plates, Hgb, Hct
    • LMWH: anti-Xa, Plates, Hgb, Hct
    • Fondaparinux: Plates, Hgb, Hct, SCr
    • Rivaroxaban: NONE
    • Apixaban: NONE
    • Argatroban: aPTT, Plates, Hgb, Hct, SCr
    • Bivalirudin: ACT (activating clotting time), Plates, Hgb, Hct, SCr
    • Dabigatran: Renal Function
    • Warfarin: PT/INR, Hct, Hgb
  2. What is the antidote of the following?
    Heparin:
    LMWH:
    Fondaparinux:
    Rivaroxaban:
    Apixaban:
    Argatroban:
    Bivalirudin:
    Dabigatran:
    Warfarin:
    • Heparin: Protamine- 1mg reverses 100 units, Max 50mg
    • LMWH: Protamine but only 60% effective
    • Fondaparinux: NONE
    • Rivaroxaban: NONE
    • Apixaban: NONE
    • Argatroban: NONE
    • Bivalirudin: NONE
    • Dabigatran: NONE
    • Warfarin: Vit K (Phytonadione-Mephyton), Kcentra (4F prothrombin complex),
  3. What are the indications of the following?
    Heparin:
    LMWH:
    Fondaparinux:
    Rivaroxaban:
    Apixaban:
    Argatroban:
    Bivalirudin:
    Dabigatran:
    Warfarin:
    • Heparin: VTE (prophyl/treat), ACS/STEMI
    • LMWH: VTE (prophyl/treat), UA/NSTEMI/STEMI
    • Fondaparinux: VTE (prophyl/treat)
    • Rivaroxaban: Non-valve A.fib, DVT/PE treat, DVT prophyl after Knee/Hip replacement
    • Apixaban: Non-valve A.fib
    • Argatroban: Used in patients with HIT
    • Bivalirudin: ACS undergoing PTCA and risk for HIT
    • Dabigatran: Non-valve A.fib
    • Warfarin: All anticoagulation uses
  4. What are the MOA of the following?
    Heparin:
    LMWH:
    Fondaparinux:
    Rivaroxaban:
    Apixaban:
    Argatroban:
    Bivalirudin:
    Dabigatran:
    Warfarin:
    • Heparin: Potentiates Antithrobin (AT), inactivates thrombin(IIa), Xa, IXa,XIa, XIIa, plasmin, prevents fibrinogen to fibrin
    • LMWH: Same as heparin but greater Xa than IIa
    • Fondaparinux: potentiates AT= "indirect Xa"
    • Rivaroxaban: Direct Xa I
    • Apixaban: Direct Xa I
    • Argatroban: Direct Thrombin I (IIa)
    • Bivalirudin: Direct Thrombin I (IIa)
    • Dabigatran: Direct Thrombin I (IIa)
    • Warfarin: C1 subunit of Vitamin K epoxide reductase enzyme (VKORC1)-depletes II, VII, IX, X, proteins C, S
  5. Major risk factors for development of Venous Thromboembolism (VTE):
    • Surgery or major trauma
    • Immobility
    • Cancer or chemotherapy
    • hx VTE
    • Pregnancy/post partum
    • Estrogen meds, SERMS
    • Obesity
  6. What is the anticoagulant drug of choice in patients that have a history of HIT?
    Argatroban
  7. How do you manage HIT per CHEST 2012 Guidelines?
    • 1. Stop heparin, LMWH, AND warfarin
    •      a. administer Vit K, warfarin use  with low platelet count increases "warfarin-induced necrosis"
    • 2. Argatroban is DOC for anticoagulation
    • 3. When platelets have recovered (>150k)
    •      a. initiate warfarin as lowered dose (max5mg)
    •      b. overlap warfarin w argatroban for minimum 5 days AND
    •      c. INR within target range for 24 hours
    •      d. urgent cardiac surgery or PCI- bivalirudin prefered
  8. What is the brand name, route of administration, and Pregnancy category of the following?
    Heparin:
    Enoxaparin:
    Dalteparin: 
    Fondaparinux:
    Rivaroxaban:
    Apixaban:
    Argatroban:
    Bivalirudin:
    Dabigatran:
    Warfarin:
    • Heparin:        same,      IV/SQ   Cat: C
    • Enoxaparin:    Lovenox   IV/SQ   Cat: B
    • Dalteparin:     Fragmin   SQ       Cat: B
    • Fondaparinux: Arixtra     SQ       Cat: B
    • Rivaroxaban:   Xarelto    PO       Cat: C
    • Apixaban:       Eliquis     PO       Cat: B
    • Argatroban: Same,         IV/SQ   Cat: B
    • Bivalirudin: Angiomax,    IV        Cat: B
    • Dabigatran: Pradaxa       PO       Cat: C
    • Warfarin: Coumadin/Jantoven PO Cat: X or D w mechanical valvue
  9. What are the colors and doses of warfarin tablets?
    • Please Let Greg Tan Bring Peaches To Your Wedding!
    • Pink         1mg
    • Lavender  2mg
    • Green       2.5mg
    • Tan         3mg
    • Blue        4mg
    • Peach      5mg
    • Teal        6mg
    • Yellow     7.5mg
    • White      10mg
  10. How to start/maintain outpatient's warfarin therapy:
    • Start 10 mg x 2 days then adjust per INR
    • Monitor INR Q 4 weeks until stable
    • Stable patients monitor Q 12 weeks
    • If stable with one out of range (≤0.5 above/below) just recheck INR in 1-2 weeks
    • Bridge for minimum 5 days and INR≥2 for 24 hours
  11. Warfarin in highly protein bound (99%). List (some) common medications that can displace warfarin:
    • I-b needin diphenhydramine and a nap cause Pheny met Val's furious bum on the dox with spiraling, gliding lips.
    • Ibuprofen, diphenhyrdramine, naproxen, phenytoin, metolazone, valproic acid, furosemide, bumetanide, doxycycline spironolactone, glyburide, glipizide,
  12. (Some) foods that are high in vitamin K:
    • Broccoli, brussels sprouts
    • Cabbage, canola oil, cauliflower chick peas, cole slaw, collard greens
    • Endive
    • Green Kale
    • Lettuce (red leaf or butterhead)
    • Mustard Greens
    • Parsley
    • Soybean oil, Spinach, Swiss chard
    • Turnip greens, Tea (green or black)
    • Watercress
  13. What is the heparin reversal agent and how is it used? BBW and SE?
    • Protamine- 1mg reverses 100 units of heparin
    • reverse the amount of heparin given in the last 2-2.5 hours; max 50mg
    • Slow IVP (50mg over 10min)
    • BBW: cardiovascular collaps, hypotension, Pulmonary: edema, vasoconstriction, hypertension
  14. What are the reversal agents used for supra-therapeutic INR levels and how are they used?? BBW and SE?
    • Phytonadione (Mephyton)/Vit K: 1-10mg PO/IV
    • IV infuse slowly not to exceed 1mg/min
    • BBW/SE- anaphylaxis- to reduce dilute in min 50mL infuse over min 20 min
    • Note- orlistat and mineral oil decrease vit K absorption
    • Kcentra(4F prothrombin complex): Body weight
    • do not let drug back-up in line(will clot)
    • CI: disseminated intravascular coagulation or HIT
    • SE: HA/N/V, arthralgia, hypotension, thrombotic events
    • Note: concurrently with vit K, Refrigerate
  15. Perioperative management of patients on warfarin therapy:
    • Stop warfarin ~5 days before major surgery
    • bridge with LMWH or heparin in high risk patients
    • but stop LMWH 24 hours or heparin 4-6 hours before surgery
    • If INR still elevated 1-2 days before surgery give low dose vit K (1-2mg)
    • If reversal in urgent surgical procedure give low dose (2.5-5mg) IV or PO vit K
    • Resume warfarin 12-24 hours post surgery when adequate hemostasis
    • LMWH- high bleed risk- resume 48-72 h w hemostasis; low bleed risk- resume 24 hours
    • continue warfarin or ASA in minor dental, dermtologic, or cataract surgery
    • Antiplatellet therapies (clopidogrel or prasugrel) may need to stop 5-10 before surgery, evaluate case by case
  16. Per CHEST guidelines, how do you anticoagulate A.fib patients?
    • A.fib > 48 hours, anticoagulate with warfarin for 3 weeks prior and 4 weeks after cardioversion while under normal sinus rhythm
    • A.fib ≤ 48 hours, undergoing elective  cardioversion, start full warfarin therapy and continue for 4 weeks while under normal sinus rhythm
    • Chronic A.fib- CHADS2 Score recommendation
  17. CHADS2 Scoring System assess the risks of VTE in patients with A.fib. How do you asses? What do the results mean?
    • Each of the following components is a risk factor: CHF(1), HTN(1), Age >75(1), Diabetes(1), prior Stroke/TIA(2)
    • Score of 0: no therapy, ASA if patient wants it
    • Score of 1: oral anticoagulation recommended, if can't then ASA and clopidogrel
    • Score of ≥2: oral anticoagulation, if can't then ASA and clopidogrel
  18. What are 2 non-pharmacological ways to prevent venous thromoembolism?
    • Graduated Compression Stockings (GCS)
    • Intermittent Pneumatic Compression (IPC)
  19. Other than bleeding and bruising, what are some symptoms that could be serious and may require the attention of the health care provider?
    • Unexpected pain, swelling, or discomfort
    • Headaches, dizziness,  or weakness
  20. Which anticoagulant can you double the dose if you missed your morning dose of the BID regimen on the same day?
    Rivaroxaban (Xarelto)

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