Anti-Coagulation

  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)
Author
HUSOP2014
ID
272377
Card Set
Anti-Coagulation
Description
NAPLEX anticoagulation review
Updated