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DSM Anticoagulation Exam 2

Terms in this set (71)

What are the clinical findings for DVT?
Red in color; no change in hair growth; warm to the touch; Unilateral edema; constant pain
What are the clinical findings for PAD?
blue/pale in color; decreased hair growth (shiny smooth skin); cold to the touch; Bilateral edema; pain with exercise
What is a positive Homan's sign?
When you dorsiflex the foot get extreme pain in the calf; sign for lower extremity DVT
What is the treatment for DVT?
anticoagulants
What is the treatment for PAD?
Statins; antiplatelets
What score is needed on the pretest probability for DVT?
Greater than or equal to 3 is a high probability; want to start anticoagulant therapy while waiting for diagnostic confirmation
What are the 3 arms in Virchow's triad?
Venous Stasis; Endothelial injury; Hypercoagulability
What are Risk factors for VTE?
Age
History of VTE
Venous stasis
Vascular Injury
Hypercoagulable states
Drug therapy
How does age influence increased risk for VTE?
Risk increases with each year of life
How does history of VTE influence increased risk for VTE?
Strongest known risk factor for VTE; risk is highest first 6
months after VTE
What are examples of Venous stasis with increased risk for VTE?
Major medical illness (eg. CHF, status post-MI), Major surgery (eg. General anesthesia > 30 minutes), Paralysis (eg. Status post-stroke, spinal cord injury),
Immobility, Polycythemia vera (make too many RBC's),
Obesity, Varicose veins
What are examples of Vascular injury with increased risk for VTE?
Major orthopedic surgery (eg. Knee and hip replacement)
Trauma (especially fractures of the pelvis, hip, or leg
Indwelling venous catheters
What are some examples of hypercoagulable states with increased risk for VTE?
Malignancy, Protein C deficiency,
Protein S deficiency, factor V Leiden, Inflammatory bowel disease, Pregnancy/postpartum
What are some drug therapies associated with increased risk for VTE?
Estrogen-containing contraception, Estrogen replacement therapy, Selective estrogen receptor modulators, Cancer therapy, Heparin-induced thrombocytopenia
How long is the initial phase of anticoagulant therapy?
1 to 7 days
How long is the long-term phase of anticoagulant therapy?
7 days to 3 months
How long is the extended coagulation phase of anticoagulant therapy?
3 months to indefinite
What is the difference between a provoked and unprovoked DVT or PE?
Provoked has reversible risk factors, Unprovoked has non-reversible risk factors.
What is the length of therapy for a provoked DVT or PE?
At least 3 months; can consider extended therapy based off patient specific factors.
What is the length of therapy for an unprovoked DVT or PE?
At least 3 months; extended therapy depends on bleed risk
What is the length of therapy for an unprovoked DVT or PE with low to moderate bleeding risk?
suggest extended therapy
What is the length of therapy for an unprovoked DVT or PE with high bleeding risk?
3 months of therapy
What is the length of therapy for DVT or PE and active cancer?
Extended therapy OR until cancer resolves
What is the choice of anticoagulant in patients with DVT of the leg or PE and no cancer (ACCP 2016 guidelines)?
Suggest dabigatran, rivaroxaban, apixaban, or
edoxaban over warfarin therapy.
What is the choice of anticoagulant in patients with DVT of the leg or PE and cancer (ACCP 2016 guidelines)?
LMWH - enoxaparin
What is the choice of anticoagulant in pregnant patients with DVT of the leg or PE (ACCP 2016 guidelines)?
LWMH - enoxaparin or UFH
What is the recommendation regarding changing the anitcoagulation in patients with DVT or PE?
no need to change the choice of anticoagulant after the first 3
months.
What is the recommendation for patients with unprovoked proximal DVT or PE stopping anticoagulation therapy?
ASA versus no ASA; unless contraindication
How long is the initial treatment of LMWH, UFH, or fondaparinux if warfarin is used as treatment for acute DVT or PE?
At least 5 days and until INR ≥ 2.0 for at least 24 hours. (not done in a-fib)
When should warfarin be initiated with UFH, LMWH or fondaparinux therapy?
On the first treatmetn day
In an outpatient setting, What is the initial dose and duration of warfarin in VTE?
10 mg daily for the first 2 days followed by dosing based on international
normalized ratio (INR) measurements + UFH, LMWH, or fondaparinux
When is an initial dose of < 5 mg of warfarin more appropriate in VTE?
Elderly, malnourished, CHF, liver disease, high risk of bleeding, or taking medications that interact with warfarin.
What is the treatment dose of Rivaroxaban in VTE?
15 mg BID for 21 days then 20 mg daily for the remainder of therapy (take with food)
What is the extended anticoagulation dose of Rivaroxaban in VTE?
10 mg daily after at least 6 months of treatment
for VTE
When should Rivaroxaban be avoided?
CrCl < 30 mL/min
What is the main counseling point when dispensing Rivaroxaban?
Take with food (largest meal of the day); increases bioavailability
What is the treatment/prevention dose of Dabigatran in VTE?
150 mg twice daily after 5-10
days of parenteral anticoagulation
When should Dabigatran be avoided?
CrCl < 30 mL/min
What is the treatment dose of Apixaban in VTE?
10 mg twice daily for 7 days, then 5 mg twice daily
What is the extended anticoagulation dose of Apixaban in VTE?
2.5 mg twice daily after at least 6 months of
treatment for VTE
When should Apixaban be avoided?
CrCl < 25 mL/min
What is the treatment/prevention dose of Edoxaban in VTE?
60 mg once daily after 5-10 days of parenteral
anticoagulation
When should the dose of Edoxaban be decreased to 30 mg daily?
Patient weight < 60 kg or with concomitant P-gp inhibitors (verapamil,
quinidine, macrolides, itraconazole, ketoconazole) or CrCl 15 to 50
mL/min
When should Edoxaban be avoided?
CrCl < 15 mL/min
What is the dose of enoxaparin in the outpatient treatment of DVT/PE?
1mg/kg
Doses available: 30,40,60,80, 100, 120, 150 (rounded to the closes whole dose)
When can enoxaparin be dosed at 1.5 mg /kg daily in the treatment of DVT/PE?
Only in an inpatient setting
What is the initial dose of Fondaparinux in the treatment of DVT or PE?
Weight based:
<50 kg = 5 mg
50 - 100 kg = 7.5 mg
> 100 kg = 10 mg
When is discharge recommended in patients with acute DVT of the leg or low risk PE?
At home treatment or early discharge is recommended over standard discharge
When is ambulation recommended in patients with an acute DVT of the leg?
Early ambulation is preferred over initial bedrest
What are compression stockings used for in patients with acute DVT of the leg?
pain and fluid build up, NOT to prevent post thrombotic syndrome
What BBW does all DOACs have?
Premature discontinuation of any DOAC increases the risk of thrombotic events
Why does warfarin not have this warning?
Longer duration of action - lasts for 5 - 7 days.
What pain medication can be used with warfarin therapy?
tylenol; unless 1.3g or more for longer than 1 week
What is a dietary consideration with Warfarin?
Vit K; or in a multivitamin
How do you switch from warfarin to Dabigatran?
Discontinue warfarin, start dabigatran when INR < 2.0
How do you switch from warfarin to Rivaroxaban?
Discontinue warfarin, start rivaroxaban when INR < 3.0
How do you switch from warfarin to Aipixaban?
Discontinue warfarin, start Apixaban when INR < 2.0
How do you switch from warfarin to Edoxaban?
Discontinue warfarin, start Edoxaban when INR < 2.5
How do you switch from Dabigatran to another DOAC?
CrCl ≥ 30 mL/min: Wait 12 hours after the last dose of dabigatran CrCl < 30 mL/min: Wait 24 hours after the last dose before initiating alternative DOAC
How do you switch from Rivaroxaban to another DOAC?
Discontinue rivaroxaban and wait 24 hours from last dose of rivaroxaban before initiating alternative DOAC
How do you switch from Apixaban to another DOAC?
Discontinue apixaban and wait 12 hours from last dose of apixaban before initiating alternative DOAC
How do you switch from Edoxaban to another DOAC?
Discontinue edoxaban and wait 24 hours from last dose of edoxaban before initiating alternative DOAC
How to switch from Dabigatran to warfarin?
Start warfarin and overlap with dabigatran (
- CrCl ≥ 50 mL/min: Use BOTH agents for 3 days
- CrCl 30 to 50 mL/min: Use BOTH agents for 2 days
- CrCl 15 to 30 mL/min:
Use BOTH agents for 1 day
How to switch from Dabigatran to warfarin when the CrCl ≥ 50 mL/min?
Use BOTH agents for 3 days
How to switch from Dabigatran to warfarin when the CrCl 30 - 50 mL/min?
Use BOTH agents for 2 day
How to switch from Dabigatran to warfarin when the CrCl 15 - 30 mL/min?
Use BOTH agents for 1 day
What do you monitor when switching from Dabigatran to warfarin?
Dabigatran may increase INR, measure warfarin's effect on INR at least 2 days after dabigatran had been stopped
How to switch from Rivaroxaban to warfarin?
Discontinue rivaroxaban and begin a parenteral anticoagulant and warfarin at the time of the next scheduled dose. Discontinue the parenteral anticoagulant when INR >2 is achieved.
How to switch from Apixaban to warfarin?
Discontinue apixaban and begin a parenteral anticoagulant and warfarin at the time of the next scheduled dose. Discontinue the parenteral anticoagulant when INR >2 is achieved.
How to switch from Edoxaban to warfarin?
Start warfarin and overlap with reduced edoxaban dosage. Reduce the dose of edoxaban by 50% (i.e., 6030mg; 30mg15mg). Discontinue edoxaban when a stable INR >2 is achieved
What do you need to monitor when switching from Rivaroxaban, apixaban and edoxaban?
INR measurements may not be useful for determining maintenance dose of warfarin
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