Indication Matters
This thrombotic event can occur if a thrombus embolizes and travels to an artery in the lungs.
What is a pulmonary embolism?
These are the factor Xa inhibitors that are used for the treatment of venous thromboembolism (VTE). Provide the generic and brand names for all.
What are, apixaban (Eliquis), edoxaban (Savaysa), and rivaroxaban (Xarelto)?
This is the mechanism of action for warfarin. Must provide the binding site AND the clotting factors that are impacted.
What is inhibition of vitamin K epoxide reductase, which leads to the depletion of factors II, VII, IX, and X?
This anticoagulant is a synthetic pentasaccharide that binds to antithrombin III and selectively inhibits Factor Xa. Provide generic only.
What is fondaparinux?
You are on your internal medicine APPE and asked by a medical resident what the dose of enoxaparin is for VTE prophylaxis. This should be your response, assuming all labs are WNL.
This is the primary reason for anticoagulation in atrial fibrillation/flutter.
What is stroke prevention?
This direct oral anticoagulant (DOAC) must be kept in its original container. Provide BOTH the generic and brand name.
This is the INR goal of a patient with VTE and a mechanical valve?
What is 2.5 to 3.5?
What would be this patient's INR goal if they did not have a mechanical valve?
This is the appropriate weight-based TWICE DAILY dosing for enoxaparin for the treatment of VTE. Must include route of administration.
What is 1 mg/kg subcutaneously twice daily?
What is 7?
This oral anticoagulant is preferred in patients with mechanical heart valves. Use BRAND name only.
What is COUMADIN or JANTOVEN?
This DOAC is preferred in patients with severe renal impairment. Provide both generic and brand name.
What is apixaban (Eliquis)?
This is the primary reason why a patient must be bridged with a parenteral anticoagulant while initiating warfarin.
What is initial decline in endogenous anticoagulants, Proteins C and S?
How long should patient bridge for and when can they stop the parenteral anticoagulant?
This parenteral anticoagulant is preferred in a patient with a history of heparin-induced thrombocytopenia (HIT) and RENAL impairment.
What is argatroban?
Bivalirudin is preferred in patients with liver disease/injury.
Misty Williams is a 34-year-old pregnant women who is being treated inpatient with enoxaparin for a VTE. ONE of the following options is the most appropriate recommendation when it comes to therapeutic drug monitoring in this patient.
A. No monitoring is required
B. Anti-Factor Xa monitoring can be considered
C. aPTT monitoring can be considered
D. INR monitoring can be considered
What is B. Anti-Factor Xa monitoring can be considered?
These anticoagulants are preferred in pregnancy.
What are unfractionated heparin and low molecular weight heparin?
What is...
- dabigatran? or
- edoxaban?
This is ONE factor of many that can INCREASE a patient's INR while on warfarin. Drug interactions are not allowed.
What is....
- Acute alcohol intoxication (i.e., binging)
- Decreased vitamin K intake
- Liver dysfunction
- Acute illness/infection
- Diarrhea/malabsorption
- Hyperthyroidism
- Older age
This is the preferred dose/route/frequency of UFH in VTE prophylaxis in a 50 year-old patient who weighs 72 kg.
What is heparin 5,000 units subcutaneously every 8 hours?
What is VTE dose/route/frequency for UFH?
Brock Harrison is a 40-year-old man who presents to your anticoagulation clinic to establish care as a new patient. You ask him to verify his warfarin regimen, and he is not sure of the tablet strengths, but states that the tablets are white and that he takes 1 tablet by mouth every day. This is Brock's warfarin regimen.
What is 10 mg PO daily (70 mg/week)?
What is the Padua VTE Prediction Score or Kucher VTE Risk Score?
You are the pharmacist rounding in the hospital and double checking the correct dosing for a patient's anticoagulant. The team is thinking of starting apixaban (Eliquis) for stroke prevention in atrial fibrillation. Their creatinine is 1.6, weight is 75 kg, and age is 81 years old. This dose of apixaban is recommended for this patient. Provide dose/route/frequency.
What is apixaban (Eliquis) 2.5 mg PO twice daily?
Remember: 2.5 mg twice daily dosing in AFIB is needed if patient meets 2 of the following: SCr>/= 1.5; Weight </= 60 kg; Age >/= 80 years.
This criteria does NOT apply to VTE dosing!
Professor Oak is a 75-year-old man who was diagnosed with atrial fibrillation 1 year ago. He cannot be on a DOAC because he has moderate-severe mitral stenosis. His current warfarin regimen is 6 mg PO daily (42 mg/week). The cardiologist wants to start amiodarone. This should be the patient's new dose of warfarin. Using best practices, you would like to stick to using only the 6 mg tablet strength if possible.
What is anywhere from 21-27 mg per week? An empiric 30-50% dose reduction in warfarin is needed. Example regimens:
- 6 mg PO daily on Mon/Thu; 3 mg on all other days (27 mg/week)
- 6 mg PO x Monday; 3 mg on all other days (24 mg/week)
- 3 mg PO daily (21 mg/week)
A 68-year-old male (85 kg) is admitted for treatment of a newly diagnosed pulmonary embolism. His past medical history includes chronic kidney disease (CrCl = 25 mL/min), hypertension, and type 2 diabetes. The team is considering starting enoxaparin. ONE of the following options is the most appropriate dose at this time. Round to the nearest syringe size.
A. 80 mg subcutaneously every 12 hours
B. 120 mg subcutaneously every 24 hours
C. 80 mg subcutaneously every 24 hours
D. 120 mg subcutaneously every 12 hours
What is C. 80 mg subcutaneously every 24 hours?
James Morgan is a 48-year-old man who presents to the emergency department with concerns after experiencing sudden-onset dyspnea, diaphoresis, and sharp chest pain. He is also hemodynamically unstable, with a BP of 82/58 mmHg. He is not on any medications and has no known diagnoses. His family states that he just returned from traveling on an extended flight (more than 12 hours). This agent, with complete generic/Brand name route, and administration directions, could be considered at this time.
What is alteplase (Activase) 100 mg IV, infused over 2 hours?