Hospital Coagu

Can you use Heparin or Enoxaparin in HIT?

No

Factors affected by Heparin?

Factor 2a and Factor Xa

How is LMWH cleared?

Renally

Cut off for Dose adjustment in LMWH for CrCl?

Under 15

Dose for a patient with a renal impairment of a person with a CrCl of 30-15

1 mg/kg QD

Two different doses for LMWH

1 mg/kg BID

1.5 mg/kg QD

What dosing regimen would be picked for an obese patient on Enoxaparin?

1 mg/kg BID

What dosing regimen would be picked for a renal impaired patient on Enoxaparin?

1.5 mg/kg QD

the BID regimen causes accumulation in body with renal impairment

What is the LMWH black box warning

Increased risk of spinal/epidural hematoma in patients undergoing spinal or epidural anesthesia or spinal puncture

What are contraindications of LMWH

• History of HIT

• Active bleeding

• Hypersensitivity

What is recommended for CrCl under 15

UFH

How is UFH eliminated

non renally

UFH dosing for VTE

• 80 units/kg bolus

• 18 units/kg/hr infusion

What monitoring is needed with UFH

aPTT (activated partial thromboplastin time) and Anti-Xa level

How often do you monitor a patient on UFH?

Every 6 hours

Why might we use UFH?

• High bleed risk patients

  • Shortest half-life and fully reversed w/ protamine

Why is treatment of VTE important?

15% of all hospital deaths

What causes the VTE risk scores to go up?

• Prior VTE

• Active cancer

• Greater than age 60

• Thrombophilia

What is considered high risk for VTE risk score?

Greater than 4

What is the initial dose of Warfarin for a prophylactic dose?

5-10 mg then adjust dose based on INR (2-3 INR)

Initial dose of Rivaroxaban for prophylaxis VTE dose?

10 mg PO QD

Initial dose of Apixaban for prophylaxis VTE dose?

2.5 mg PO daily

Initial dose of ASA for prophylaxis VTE dosing?

325 mg PO BID

What is the non-pharmacological prophylaxis treatments for VTE?

Compression elastic stockings

Intermittent pneumatic compression

What are the goals of Therapy for treatment of VTE

• Prevent Acute PE

• Reduce mortality

• Prevent development of complications

When do you use t-PA in treatment of PE

Is the patient hypotensive, and are they normotensive

• 100 mg of PE treatment

  • Followed by heparin or other anticogulation

Dosing VTE for rivaroxaban

15 mg BID for 21 days

20 mg QD for 21 days

Dosing VTE for Apixaban

10 mg BID for 7 days

5 mg BID for 7 days

Dosing VTE for Dabigatran

after a parenteral anticoagulation for 5-10 days

150 mg BID

What medication is used in treatment for a Direct Thrombin Inhibitors

Argatroban (FDA approved for HIT)

What is important to remember about INR and Argatroban

False elevation of PT/INR

What is Bivalirubin indicated for?

HIT

How are the HIT treatment drugs cleared?

• Bivalirubin (liver)

• Argatroban (renally)

How long should you bridge with Warfarin?

minimum for 5 days and until INR is or above for atleast hours

when to stop Apixaban prior to surgery?

High risk of bleeding - 3 days

Low risk of bleeding - 2 days

when to stop Dabigatran (> or = to 50 mL/min) prior to surgery?

High risk of bleeding - 3 days

Low risk of bleeding - 2 days

when to stop Dabigatran (< or = to 50 mL/min) prior to surgery?

High risk of bleeding - 5 days

Low risk of bleeding 3 days

When to stop Rivaroxaban prior to surgery?

High bleeding risk of bleeding - 3 days

Low risk of bleeding - 2 days

When can you start warfarin after surgery?

day of procedure or next day

When can you resume LMWH after surgery?

24-72 hours after surgery depending on bleed risk

When do you stop wafarin pre surgery?

5 days for low - high bleed risk

When do you have to not stop warfarin?

When there is minimal-bleed-risk

When do you start DOACs after surgery?

High risk - 2 days after surgery

Low risk - 1 day after surgery

What is the reversal agent of Heparin

Protamine Sulfate

What are the possible allergies of protamine sulfate

fish/salmon allergy

When would you not need to use Kcentra?

If surgery can be delayed by 12 hours

What is a potential reversal agent of all anticoagulants (heparin, LMWH, and DOACs)

Ciraparantag (aripazine)

Aminocaproic Acid drug class

Antifibrinolytic