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What are the monitoring parameters of the following?
- 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
What is the antidote of the following?
- 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),
What are the indications of the following?
- 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
What are the MOA of the following?
- 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
Major risk factors for development of Venous Thromboembolism (VTE):
- Surgery or major trauma
- Cancer or chemotherapy
- hx VTE
- Pregnancy/post partum
- Estrogen meds, SERMS
What is the anticoagulant drug of choice in patients that have a history of HIT?
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
What is the brand name, route of administration, and Pregnancy category of the following?
- 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
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
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
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,
(Some) foods that are high in vitamin K:
- Broccoli, brussels sprouts
- Cabbage, canola oil, cauliflower chick peas, cole slaw, collard greens
- Green Kale
- Lettuce (red leaf or butterhead)
- Mustard Greens
- Soybean oil, Spinach, Swiss chard
- Turnip greens, Tea (green or black)
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
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
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
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
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
What are 2 non-pharmacological ways to prevent venous thromoembolism?
- Graduated Compression Stockings (GCS)
- Intermittent Pneumatic Compression (IPC)
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
Which anticoagulant can you double the dose if you missed your morning dose of the BID regimen on the same day?