AC

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Snooze
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282569
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AC
Updated:
2014-09-12 20:00:37
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AC prep
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  1. 1. Prothrombin --->?
    2. What factor is PT?
    3. What activate PT?
    Prothrombin ---> Thrombin

    PT (factor II) ---> Thrombin (factor IIa)

    Factor Xa activates PT
  2. What are the 3 drugs that bind to antithrombin III (AT)?
    • HEPARIN
    • LMWH
    • Fondaparinux (Arixtra)
  3. What are 3 drugs (SC and PO) that inhibits Factor Xa?
    • SC - Fondaparinux (Arixtra)
    • SC - Enoxaparin (Lovenox)
    • PO - Rivaroxaban (Xarelto)
  4. What is the only oral DTI available currently?
    Dabigatran (Pradaxa)
  5. What is the drug class of choice for HIT?
    Injectable DTI's (Argatroban, Lepirudin)
  6. Heparin blocks which coagulation pathway?
    Intrinsic pathway (contact activation, damaged surface activated)
  7. What is the therapeutic aPTT/PTT for heparin? 

    How often do you check aPTT until therapeutic?
    45-70 seconds

    Check before initiation, check every 6 hours until 2 therapeutic readings. Then check
  8. What are the dosage forms of heparin?
    1000 units/ml, 2500 units/ml, 5000 units/ml, 7500 units/ml, 10,000 units/ml, 20,000 units/m
  9. What specific labs should be monitored for heparin? (3) Why?
    • Hgb
    • Hct
    • PLT

    Monitor for bleeding and HIT
  10. When do you dose-adjust renally for heparin?
    No renal dose-adjustments
  11. What is the PTT goal for heparin subc?
    PTT unaffected so not monitored
  12. What is the alternative for warfarin in pregnant women?
    Heparin - large molecule that doesnt cross
  13. What is the VTE prophy dose for heparin? Where can you administer?
    5000-10,000 units subc q8-12hrs 

    Inject in lower abdomen, inner thighs, or upper arms
  14. What are the 3 G herbs that increase risk of bleeding?
    Ginger, garlic, ginkgo biloba 

    (ginseng decreases INR with warfarin)
  15. When does HIT usually occur with heparin use?

    How much would PLTS have to drop from baseline to be considered as thrombocytopenia?
    HIT occurs 5-14days usually after initiation of heparin

    PLT drop >50% from baseline = thrombocytopenia
  16. How does HIT occur in heparin use? What if it is left untreated?
    Immune system forms IgG antibodies against heparin when it binds to platelet factor 4 (PF 4). IgG + heparin + PF 4 forms a complex that binds to platelets, leading to platelet activation and thus a pro-thrombotic state.

    If untreated, may lead to venous/arterial thrombosis and amputations, post-thrombotic syndrome, and/or death
  17. For HIT, what is the DOC for pts with renal impairment? Hepatic impairment?

    What is the DOC for pts with urgent cardiac surgery or PCI?
    • Renal impairment = argatroban
    • Hepatic impairment = lepirudin 
    • Cardiac surgery or PCI = bivalirudin
  18. For HIT pts, when would you initiate warfarin?
    When PLT at least 150,000/mm3, overlap with nonheparin anticoagulant for a minimum of 5 days
  19. What is the antidote dose for heparin and LMWH overdose? Max dose?
    1mg protamine for 100 units heparin

    Max dose 50mg

    1mg protamine for 1mg enoxaparin
  20. What is the treatment dose for VTE for heparin?

    What type of weight would you use for dosing?
    80units/kg IV bolus followed by 18units/kg/hr infusion OR 5000units IV bolus followed by 1000units/hr infusion

    Use actual body weight
  21. What are 5 main s/e of heparin? (including 1 long-term s/e)
    • Bleeding
    • Thrombocytopenia
    • HIT
    • HyperK
    • Osteoporosis (long-term use)
  22. What is the difference b/w type I and type II HIT?
    Type 1 is not immune-mediated and occurs within 1st 48h of heparin use and results in mild decrease in PLT.

    Type 2 is immune-mediated and occurs 5-14d after heparin use
  23. What are the 3 risk factors associated with HIT in heparin pts?
    • Heparin for 4 days
    • Female sex
    • Recent surgery
  24. What is 1 of the procoagulants that is produced during HIT?
    Thrombin (Factor IIa)
  25. What is the most common diagnostic tool for HIT?
    Solid-phase enzyme immunoassays (EIA) to detect HIT antibodies
  26. When a pt is diagnosed with HIT, which is the best for pt after d/c heparin? 
    Administer warfarin
    or transfuse platelets?
    Neither. Both may potentiate procoagulant state
  27. What is the duration of tx for HIT with DTI's?
    Minimum of 30 days. If thrombosis occurs, tx with anticoagulant for minimum of 6
  28. When would one initiate warfarin in pt resolved with HIT?
    After PLT>100,000/mm3, may initiate 5 days before alternate anticoagulant is d/ced
  29. For enoxaparin, what is the DVT prophy dose for hip, knee replacement? For abdominal surgery?
    When to initiate? 
    Renal dosing?
    Hip: 30mg sc q12h 12-24hr post-op or 40mg sc daily 9-15hr pre-op for at least 10 days up to 35 days  

    knee: 30mg sc q12h. Start 12-24h post-op for 7-10 days, up to 35 days 

    Abd surgery: 40mg sc daily. Start 2hrs pre-op, for NMT 12 days 

    Both: CrCL<30: 30mg sc daily
  30. What is DVT/PE tx dose with enoxaparin? Renal dosing?
    1mg/kg sc BID, or 1.5mg/kg daily

    CrCL<30: 1mg/kg sc daily
  31. What is dosing of enoxaparin for MI, unstable angina, thrombolytic adjunct, and PCI?  Renal dosing? Age >75?
    • 1mg/kg sc q12h with ASA 
    • Age>75: 0.75mg/kg sc q12h
    • CrCL<30: 1mg/kg sc daily
  32. What kind of allergy should one be cognizant about for heparin and LMWH?
    Pork
  33. What are the dosage forms of enoxaparin?
    30/0.3ml, 40, 60, 80, 100mg/ml, 120mg/0.8ml, 150mg/ml pre-filled syringes
  34. What are the dosage forms of fondaparinux?
    2,5, 5, 7.5, 10mg pre-filled syringes
  35. What is the BBW for enoxaparin? For fondaparinux? For desirudin?
    Pt receiving anesthesia (epidural, spinal) or undergoing spinal puncture are at risk for hematomas and subsequent paralysis
  36. What is DVT prophy dose for fondaparinux and duration? When do u initiate? Any restrictions?
    • 2.5mg sc daily 6-8hrs post-op for 10 days, up to 35 days
    • CI in adults <50kg
  37. What is renal dose-adjustment for fondaparinux for DVT prophy n tx?
    CrCL<30: Use is CI
  38. What is dose of fondaparinux for VTE tx and duration?
    • Wt<50kg: 5mg sc daily
    • 50-100kg: 7.5mg sc daily
    • >100kg: 10mg sc daily
    • for 5-9 days up to 26 days
  39. What are the brand names for DTI's - argatroban, lepirudin, and bivalirudin?
    • Argatroban (Novastan)
    • Lepirudin (Refludan)
    • Bivalirudin (Angiomax)
  40. When do you start renally dose-adjusting for argatroban, lepirudin, bivalirudin, and desirudin?
    • Argatroban: No renal d-adj req'd
    • Lepirudin: CrCL<60 
    • Bivalirudin: CrCL<30
    • Desirudin: CrCL<60
  41. What is the only indication for desirudin (Ipravask) and dosing?
    VTE prophy for hip replacement: 15mg sc q12h
  42. What are the dosage forms of dabigatran? How long is it good for after opening? Storage instructions? How long are blister packs good for?
    • 75, 150mg caps
    • Use within 4 months, keep in original container and protect from moisture 

    Blister packs: Good until exp date (~6-12 mons)
  43. What are the renal dose-adjustments for dabigatran? What is indication and dosing?
    • Non-valvular A-fib: 150mg po BID 
    • CrCL<30: 75mg po BID
    • CrCL<15: DO NOT USE
  44. When do you initiate warfarin with dabigatran based on CrCL?
    • CrCL>50: Initiate warfarin 3 days before d/c dabigatran
    • CrCL 31-50: Initiate warfarin 2 days b4 d/c dabigatran
    • CrCL 15-30: Initiate warfarin 1 day before d/c dabigatran
    • CrCL<15: No recommendation
  45. Besides bleeding, what other common s/e occurs with dabigatran? And why does this occur?
    Dyspepsia, abd discomfort

    Better absorbed at lower pH, so caps have an acidic core that can cause GI irritation
  46. Compared to warfarin, how many more strokes are prevented in Afib pts with dabigatran?
    5 more strokes prevented per 1000 pts/yr
  47. What is the BBW for rivaroxaban?
    Pt receiving neuraxial anesthesia (epidural, spinal) or undergoing spinal puncture are at risk for hematomas and subsequent paralysis.

    D/C of drug in pt w/non-valv Afib can put pt at inc'd risk of thrombosis (i.e. stroke)
  48. What are the 3 indications for rivaroxaban?
    • Non-valv Afib
    • Prophy for DVT in hip/knee surgery
    • Tx of DVT/PE
  49. What are the dosage forms of rivaroxaban? What is its metabolism?
    • 10, 15, 20mg oral tabs
    • Major 3A4 substrate
  50. What is dosing of rivaroxaban for non-valv Afib? Renal d-adj?
    • CrCL>50: 20mg po daily with dinner
    • CrCL 15-50: 15mg po daily with dinner
    • CrCL<15: Avoid use
  51. What is dosing for rivaroxaban for DVT prophy after hip/knee surgery? Renal d-adj? Duration?
    10mg po daily w/o regard to meals, for 35 days (hip), or 12 days (knee)

    Do not use in CrCL<30
  52. What is dosing of rivaroxaban in VTE tx? Renal d-adj?
    • 15mg po bid wf x21d, then 20mg po daily wf
    • CrCL<30: Do not use
  53. What is the BBW for warfarin? And what are 3 side efx to watch out for?
    May cause major or fatal bleeding

    Bleeding, skin necrosis, purple toe syndrome
  54. How is warfarin metabolized (substrate, etc)?
    • Major CYP2C9 substrate
    • Minor 1A2, 2C19, and 3a4 substrate
    • Weak 2C9/19 inhibitor
  55. What are some CYP inducers (7) that could decrease INR with warfarin?
    • Aprepitant 
    • Bosentan
    • CBZ
    • Pb
    • PHT
    • Primidone
    • Rifampin
  56. What are some 2C9 inhibitors that might increase INR with warfarin? (8)
    • Amiodarone
    • Bactrim
    • Azole antifungals
    • Fluvastatin 
    • Fluvoxamine
    • Macrolide Abx
    • Metronidazole
    • Tigecycline
  57. Which 2 herbs/supplements may reduce effectiveness of warfarin (may dec INR)?
    • Ginseng
    • CoQ10
  58. For warfarin pt that is bleeding and needs vitamin K, what are the 2 preferred routes (and which is preferredover the other?)?
    • IV inj
    • PO 

    • IV causes anaphylaxis in 3/100,000 pt so infuse slowly 
    • SC -- variable response
    • IM - hematoma formation risk
  59. What 3 minor surgeries does not warrant warfarin temp d/c?
    • Minor dental
    • Dermatologic
    • Cataract surgery
  60. What is anticoag recommendation for pt with Afib>48hrs or unknown duration, who will be recieving cardioversion in the future?
    Anticoagulate for at least 3 weeks prior to and 4 weeks after cardioversion when NSR is restored
  61. What is anticoag recommendation for pt in Afib<48hr undergoing elective cardioversion?
    Start full therapeutic anticoag at presentation and continue for at least 4 weeks after cardioversion while pt is in NSR
  62. What are the half-lives of the Vit-K--dep factors blocked by warfarin?
    • II: 60hrs
    • VII: 6hrs 
    • IX: 24hrs 
    • X: 40 hrs
  63. Per ACCP, what are Vit K recommendations for warfarin users when:
    1. INR >10 w/o bleed
    2. INR any value with major bleed
    Check ACCP and update
  64. When do you convert warfarin to dabigatran? When can one see true INR value after dabigtran is converted to warfarin?
    Warfarin to Dabigatran when INR<2.0 

    After d/c dabigatran for 2 full days, will see INR effects from warfarin (since Pradaxa affects INR)

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