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Therapeutic Dosing > Final part 3 > Flashcards

Final part 3 Flashcards

1
Q

Heparin MOA

A

binds with antithrombin to inactivate factors 10 & 2

- also 9, 11 & 12

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2
Q

no renal dose adjustments for

A

heparin & warfarin

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3
Q

prior to initiation of heparin therapetic doses must know:

A

indication
total body weight
baseline aPTT/anti-Xa & plts
- double check hgb

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4
Q

heparin for VTE

A

80u/kg then 18u/kg/hr

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5
Q

heparin for ACS

A

60u/kg then 12 u/kg/hr

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6
Q

heparin for VTE prophylaxis

A

500u SQ Q8-12H

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7
Q

heparin aPTT monitoring

A

may stop Q6H monitoring after 2 aPTTs in range & go to daily checks
- plts Q3 days

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8
Q

prophylactic monitoring for heparin

A

none

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9
Q

lovenox generic

A

enoxaparin

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10
Q

lovenox MOA

A

binds antithrombin to inactivate factors (X>II)

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11
Q

dosing considerations of enoxaparin

A

indication
renal function
total body weight

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12
Q

therapeutic dosing for enoxaparin

A
  • 1mg/kg Q12H if CrCl>30

- QD if CrCl

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13
Q

VTE prophylaxis enoxaparin dose

A
  • medical/surgical:40mg SQ QD
  • knee replacement: 30 SQ BID
  • CrCl
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14
Q

enoxaparin monitoring

A
  • anti-Xa
  • indicated with treatment doses in:
    prego, wt 190kg
  • CrCl
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15
Q

enoxaparin anti-Xa level targets

A
  • Q12H CrCl>30 or QD CrCl 30:1-2

- prophylaxic: 0.2-0.6

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16
Q

fragmin generic

A

dalteparin

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17
Q

dalteparin MOA

A

binds with antithrombin to inactivate factors X>II

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18
Q

dalteparin prophylaxis dosing

A

500u SQ daily

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19
Q

what is the agent of choice for reversal of heparinoids?

A

protamine sulfate

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20
Q

arixtra generic

A

fondaparinux

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21
Q

fondaparinux indications

A
  • VTE prophylaxis: 2.5mg SQ QD
  • VTE treatment: (100:10mg)
  • CI in CrCL
22
Q

MOA of argatroban

A

direct thrombin inhibitor

23
Q

argatroban indications

A
  • prevention/treatment of HIT

- PCI

24
Q

argatroban monitoring

A
  • aPTT

- prolongs INR

25
Q

consider addition of warfarin to argatroban infusion when:

A

confirmed HIT PLUS plts >150

26
Q

overlap warfarin & argatroban for

A

at least 5 days before dc argatroban

27
Q

angiomax generic

A

bivalirudin

28
Q

bivalirudin MOA

A

direct thrombin inhibitor

29
Q

bivalirudin dosing

A
  • PCI: 0.75mg/kg x1 then 1.75mg/kg/hr

- HIT:0.15-0.2mg/kg/hr

30
Q

bivalirudin monitoring

A
  • HIT: aPTT levels

- PCI: once time ACT

31
Q

peri-operative for heparin

A

hold 4-6 hours before surgery & weight 48-72 hours after for high risk bleeders (24 for non-high risk)

32
Q

peri-operative for LMWH

A
  • 24 hours before & 24 hours after
33
Q

warfarin MOA

A
  • inhibits vitamin K epoxide reductase (VKOR) complex to reduce vitamin K available for the synthesis of SNOT, & Protein C & S
34
Q

warfarin initial dose

A

5mg PO QD (5-10)

- may use 10mg x 2 day loading dose if healthy

35
Q

sensitivity factors for warfarin

A
  • use 2.5mg QD
  • age over 75
  • liver or renal disease
  • HF
  • high bleeding risk
  • drug interaction
  • acute etOH intake
  • smoking cessation
  • poor nutritional status
  • infection
  • malignancy
36
Q

cyp2c9 & Vkorc1 genotyping

A
  • currently not recomended
37
Q

agents that increase warfarin efficacy & bleeding

A 
amiodarone
fluconazole
metronidazole
NSAIDs
sulfonamides
"G" herbals
other anticoags
38
Q

agents that decrease warfarin efficacy

A

rifampin
st johns wort
carbamazepine

39
Q

INR measures factors

A

II, VII, & X

40
Q

warfarin titration

A

INR:

  • less than1.5: incr wk 10-20%
  • 1.5-1.9:incr wk 5-15%
  • 2-3 continue
  • 3.1-3.5: decr wk 5-15
  • 3.6-4.4: dec 10-20% & hold 2 doses
  • more than 4.5: follow flow chart
41
Q

warfarin INR follow up times

A
  • initiation (outpt): 5-7 days
  • out of range (less than 4.5) or 1 INR in range: 1-2 wks
  • 2 or more in range: 4 wks
  • severe bleeding: PRN
  • INR more than 10: 1-2 days
  • INR 4.5-10: 2-3 days
42
Q

warfarin bridging therapy is most appropriate in:

A

VTE, Afib & valve replacement

  • initiate warfarin & IV anticoag on day 1
  • for at least 5 days until 2 INRs are above 2 24 hours apart
43
Q

pradaxa generic

A

dabigatran

- direct thrombin inhibitor

44
Q

pradaxa dosing

A
  • 150mg PO BID
  • must complete 5-10 days IV
  • DVT or nonvalv AF
45
Q

xarelto generic

A

rivaroxaban

- factor Xa inhibitor

46
Q

xarelto dosing

A
  • acute DVT: 15mg PO BID x21 then 20mg QD
  • nonvalv: 20mg QD
  • prophylaxis: 10mg QD
47
Q

eliquis generic

A

apixaban

- factor Xa inhibitor

48
Q

eliquis dosing

A
  • DVT: 10mg PO ID x7 days then 5mg BID
  • nonvalv: 5mg BID
  • prophylaxis: 2.5mg BID
49
Q

savaysa generic

A

endoxaban

- factor Xa inhibitor

50
Q

savaysa dosing

A
  • dvt: 60mg QD
  • must complete 5-10 days IV
  • nonvalv: 60mg qd
  • do not use in crcl above 95 or less than 15

Therapeutic Dosing (3 decks)

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