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NAPLEX Review โ Anticoagulation Questions
With Complete Solutions
what is the MOA of UFH? - bind to antithrombin DIRECTLY and accelerate its ability to inactivate thrombin and factor Xa and prevent the conversion of fibrinogen to fibrin what type of inhibitor of thrombin is UFH? - direct thrombin inhibitor what body weight measurement do we use for UFH? - total body weight what are some contraindications for use of UFH? - uncontrolled/active bleeding, hx of HIT, hypersensitivity to pork products what form of UFH should not be used in neonates, infants, pregnant individuals, and those breastfeeding? - products that contain benzyl alcohol what are some side effects of UFH? - bleeding, thrombocytopenia, HIT, hyperkalemia, and osteoporsis w/ long term use what needs to be monitored while on UFH? - aPTT or anti-Xa levels, platelets, HGB, HCT
when using UFH, at what time after initiation should aPTT or anti-Xa levels be checked? - 6 hours after initiation then 6 hours thereafter until therapeutic what change in platelets is suggestive of HIT? - >50% decrease in platelets what is the antidote of UFH? - protamine what route of aministration should be avoided with UFH? - IM what risk is associated with UFH given via IM? - hematomas what type of anticoagulant is enoxaparin? - LMWH what is the brand name of enoxaparin? - lovenox what weight should we use in the dosing of enoxparin? - total body weight does enoxaparin require anti-Xa monitoring? - no when is anti-Xa monitoring recommended in enoxaparin use? - pregnancy if youre measure anti-Xa in enoxaparin use, when should levels be taken? - 4 hours post SQ dose what is the antidote for enoxaparin? - protamine
what type of drug is rivaroxaban? - oral direct factor Xa inhibitor what is the bran name of rivaroxaban? - xarelto what pearls should be known for rivaroxaban doses >/= 15 mg?
- take with food what conditions should rivaroxaban not be used in? - prosthetic heart valves, antiphospholipid syndrome, moderate to severe hepatic impairment can rivaroxaban be used in antiphospholipid syndrome? - no what labs should be monitored with rivaroxaban? - HGB, HCT, SCr, LFTs what is the antidote for rivaroxaban? - andexant alfa when should rivaroxaban be d/c'd prior to surgery? - 24 hours what type of drug is edoxaban? - oral direct facot Xa inhibitor what is the brand name of edoxaban? - savaysa what kidney function cut off should you not use edoxaban? - CrCl > can you use edoxaban in antiphospholipid syndrome? - no when should edoxaban be d/c'd prior to surgery? - 24 hours
what type of drug is fondaparinux? - direct factor Xa inhibitor is fondaparinux an oral drug? - no what is the brand name of fondaparinux? - arixta is there an antidote for fondaparinux? - No what are some side effects of fondaparinux? - bleeding, hypokalemia what are some of the oral direct thrombin inhibitors? - dabigatran what type of drug is dabigatran? - oral direct thrombin inhibitor what is the brand name of dabigatran? - pradaxa what should you do if you miss a dose of dabigatran? - take immediately unless dose is within the next 6 hours when is the use of dabigatran contraindicated? - mechanical prosthetic heart valves what are some side effects of dabigatran? - dyspepsia, gastritis like symptoms, bleeding what is the antidote of dabigatran? - idarucizumab what is the brand name of idarucizumab? - praxbind
what should you do if you miss a dose of warfarin? - take dose immediately, do not double dose what is the typical starting dose of warfarin in healthy outpatients? - </= 10 mg daily for the first 2 days what is the typical starting dose of warfarin in patients who are elderly, malnourished, on drugs that INCREASE warfarin levels, liver disease, heart failure, or high risk of bleeding? - </=5 mg what are the contraindications of warfarin? - pregnancy (except with mechanical valves at high risk for thromboembolic events), uncontrolled HTN when is it acceptable to use warfarin in pregnancy? - mechanical heart valves who are at high risk of thromboembolic events what are some warnings with warfarin? - tissue necrosis, gangrene, HIT, presence of CYP2C9*2 or 3 alleles, polymorphisms of VKORC what alleles are associated with warfarin metabolism? - CYP2C92 and * what are some serious side effects of warfarin? - skin necrosis, purple toe syndrme what is the goal INR on warfarin for VTE? - 2-
what is the goal INR on warfarin for afib? - 2- what is the goal INR on warfarin for bioprosthetic mitral valve?
- 2- what is the goal INR on warfarin for mechnical aortic valve? - 2- 3 what is the goal INR on warfarin for antiphospholipid syndrome? - 2- what anticoagulant is safe to use in antiphospholipid syndrome?
- warfarin what conditions is the goal INR 2-3 on warfarin? - VTE, afib, bioprosthetic mitral valve, mechanical aortic valve, antiphospholipid syndrome what is the goal INR on warfarin for mechanical mitral valve? - 2.5-3. what is the goal INR on warfarin for 2 mechanical heart valves?
- 2.5 - 3. what conditions is INR of 2.5-3.5 on warfarin goal? - mechanical mitral valves, 2 mechanical heart valves what is the antidote of warfarin? - vitamin K what is the reversal agent for UFH/LMWH? - protamine sulfate
what are the boxed warnings for vitamin K? - hypersensitivity reactions what are some pearls of administration of phytonadine? - requires light protection during admin can phytonadine be given SQ? - no why can phytonadine not be given SQ? - variable absorption can you give phytonadine via IM? - no why can phytonadine not be given IM? - hematomas what is four factor prothrombin complex concentrate? - warfarin reversal what is the brand name for four factor prothrombin complex concentrate? - Kcentra what factors are in four factor prothrombin complex concentrate? - 2, 7, 9, 10 what proteins are in four factor prothrombin complex concentrate? - C, S what is contained in four factor prothrombin complex concentrate? - factors 2, 7, 9, 10, and protein C, S when are anticoagulants used? - prevention and tx of VTEs
what factors does warfarin inhibit? - factors 2, 7, 9, and 10 what can be said about the activity of LMWH? - more anti-Xa activity than anti-2a activity what oral anticoagulants are used in VTE prevention? - warfarin, factor Xa inhibitors, thrombin inhibitors what oral anticoagulants are used in VTE treatment? - warfarin, factor Xa inhibitors, thrombin inhibitors what oral anticoagulants are used in prevention of stroke in patients with afib? - warfarin, factor Xa inhibitors, thrombin inhibitors in most conditions what group of anticoagulants preferred? - DOACs what are the DOACs? - factor Xa inhibitors and thrombin inhibitors why are DOACs preferred over warfarin? - less drug interactions, less bleeding, dosing based on kidney/liver function does warfarin need to be adjusted based on kidney or liver function? - no in moderate to severe mitral stenosis what anticoagulant is preferred? - warfarin in mechanical valve what anticoagulant is preferred? - warfarin
when in general are oral anticoagulants used? - afib stroke prevention, DVT/PE treatment and prevention what type of immune reaction is HIT? - IgG how does HIT happen? - immune reaction leading to platelet activation and then a prothrombic state what is the assessment tool for HIT? - 4 T score what are the criteria of the 4T score? - thrombocytopenia, timing of platelet count, thrombosis with regards to thrombocytopenia, what is the defining feature for HIT? - unexplained >50% drop in platelet count from baseline with regards to the timing of platelet drops, what is the defining feature of HIT? - 5-10 after the start of heparin OR within a couple hour sif patient previously exposed within the past 3 months what is the management of HIT? - stop all forms of heparin what is the management of HIT if the patient is on warfarin? - d/c and give vitamin K what is the management of HIT if you still need anticoagulation? - argatroban
when can you start warfarin therapy after HIT? - once platelets
150k what is the preferred anticoagulant in HIT if PCI or cardiac surgery is required? - bivalirudin what is apixaban a major substrate of? - CYP3A4 and PGP what drug metabolism should you avoid in the use of apixaban?
- strong dual inducers of CYP3A4 and PGP what drugs should be avoided when using apixaban? - carbamazepine, phenytoin, rifampin, st johns wort what is rivaroxaban a major substrate of? - CYP3A4 and PGP what drug metabolism should be avoided in rivaroxaban use? - strong dual inducers what drugs should be avoided in rivaroxaban due to drug interactions? - carbamazepine, phenytoin, rifampin, st johns wort, ketoconazole, itraconazole, iopinavir/ritonavir, ritonavir, conivaptan what is edoxaban a substrate of? - PGP what drugs should be avoided in use with edoxaban due to drug interactions? - rifampin what is dabagatran a substrate of? - PGP
when using CYP2C9 inhibitors with warfarin, what happens to the INR? - increased INR what drugs will increase the INR in warfarin use? - amiodarone, fluconazole, ketoconazole, voriconazole, capecitabine, cimetidine, fluvastatin, fluvoaxime, metronidazole, tamoxifen, tigecycline, TMP/SMX how should warfarin dose be adjusted in the use of amiodarone?
- decrease warfarin dose by 30-50% what drug should absolutely be avoided in combination with warfarin due to metabolism interactions? - tamoxifen in general, what do antibiotics due to warfarin effects? - increase anticoagulant effects in general, what drugs increase the bleeding risk in warfarin but leave the INR unchanged? - NSAIDs, antiplatelets, other anticoagulants, SSRIs, SSNRIs in general, what drugs increase the clotting risks with warfarin and should be d/c'd? - estrogen, SERMs what dietary supplements can increase the risk of bleeding with warfarin use? - chamomile, chondroitin, dong quai, high doses of fish oil, garlic, ginger, gingko, gingseng, glucosamine, vitamin E, willow bark
what dietary supplements can decrease the effectiveness of warfarin? - green tea, co-Q10, st johns wort what foods are high in vitamin K, and thus may make warfarin less effective? - cooked spinach, brocoli, brussel sprouts, collard greens, kale in patients being treated for DVT/PE, when should warfarin start in regards to the initiation of parenteral anticoagulation? - same day as parenteral anticoagulation how long do you use warfarin and parenteral anticoagulants together in the treatment of a DVT/PE? - minimum of 5 days and until the INR is >/= 2 for at least 24 hours what is the LONGEST you can go for measuring the INR of a patient on warfarin given their INR has been stable? - 12 weeks what is the pneumonic to remember the colors of warfarin tablets? - please let greg brown bring peaches to your wedding what is the dose of the PINK warfarin tablet? - 1 mg what is the dose of the LAVENDER warfarin tablet? - 2 mg what is the dose of the GREEN warfarin tablet? - 2.5 mg what is the dose of the BROWN/TAN warfarin tablet? - 3 mg what is the dose of the BLUE warfarin tablet? - 4 mg
when is IV vitamin K indicated in warfarin reversal? - patient is experiencing serious bleeding if a patient on warfarins INR is above therapeutic range, but <4.5, w/o bleeding, what should be done? - reduce or skip warfarin dose, continue to monitor INR if a patient on warfarins INR is supratherapeutic, between 4.5- 10, w/o bleeding, what should be done? - hold 1-2 doses of warfarin is vitamin K recommended in patients on warfarin who's INR is supratherapeutic (4.5-10) w/o bleeding? - it is not recommended, no evidence of bleeding if a patient on warfarins INR is >10 w/o bleeding, what should be done? - hold warfarin, give vitamin K 5-10 mg slow IV injection and four factor prothrombin complex concentrate when is vitamin K indicated in warfarin use w/o bleeding? - INR
how long prior to surgery should a patient on warfarin d/c? - 5 days prior to surgery what are the modifiable risk factors for VTEs? - acute medical illness, immobility, obesity, medications, pregnancy, post- partum, recent surgery or major trauma
what drugs are considered a modifiable risk factor for VTE? - SERMs, drugs containing estrogen, ESA what are the nonmodifiable risk factors for VTEs? - increasing age, cancer, chemotherapy, previous VTE, inherited or acquired thrombophilia, certain disease states what are the disease states that are a risk factor for VTEs? - heart failure, nephrotic syndrome, respiratory failure what drugs are approved for VTE prophylaxis? - UFH, LMWH, fondaparinux, rivaroxaban, apixaban, dabigatran if a patient is at risk for VTEs and is going to travel a long distance, is the use of anticoagulants or ASA indicated? - not indicated how long should you treat a VTE caused by a modifiable risk factor or surgery? - 3 months when is long term VTE prophylaxis/tx indicated? - two unprovoked episodes of VTE for patients w/o cancer, what are the preferred anticoagulants over warfarin for the first 3 months of tx of DVT/PE? - dabigatran, rivaroxaban, apixaban, edoxaban for patients w/ cancer, what anticoagulants are preferred? - rivaroxaban, apixaban
