Dosing
What lab parameter are heparin rates adjusted to?
PTT
When switching a patient to Eliquis from lovenox, when is it appropriate to start the Eliquis?
Within 2 hours of the next scheduled lovenox dose
A patient presents with an INR of 8.2, no signs or symptoms of bleeding, and their last warfarin dose was 12 hours ago. Would you give KCentra (4 factor prothrombin complex concentrate with factors II, VII, IX, and X)?
No, only Vitamin K would be indicated for this patient.
How often is the INR checked for an inpatient anticoagulated on warfarin?
Daily
What agents are not preferred in a patient that does not consume pork products?
Heparin and Lovenox
What is the initial dosing scheme for Xarelto for DVT treatment? (loading and maintenance)
15mg twice daily for 21 days followed by 20mg daily
When transitioning a patient to Xarelto from warfarin, when is it appropriate to hold the warfarin and start the new DOAC?
When the INR falls below 3
"READ" INR goals:
Rivaroxaban: <3
Edoxaban: <2.5
Apixaban: <2
Dabigatran: <2
What is the reversal agent for Eliquis?
Andexanet alfa, but at YNHH we use KCentra
What is the routine monitoring for a patient on a DOAC?
DOAC do not require routine monitoring
What is the goal INR range for a patient with a mechanical mitral valve?
2.5-3.5
What are the 3 criteria evaluated for a dose reduction of Eliquis when treating AFib?
2 of the following 3:
Age >80 years
Body weight <60kg
SCr > 1.5mg/dL
When transitioning a patient to Eliquis from warfarin, when is it appropriate to hold the warfarin and start the new DOAC?
When the INR falls below 2
"READ" INR goals:
Rivaroxaban: <3
Edoxaban: <2.5
Apixaban: <2
Dabigatran: <2
What is the reversal agent for dabigatran (Pradaxa)?
Praxbind (idarucizumab)
After how many days does warfarin begin to affect the INR?
~3 days due to the half lives of the factors two, seven, nine, and ten.
VII ~ 4-6 hours
IX ~ 20 hours
X ~ 30 hours
II - ~60 hours
What is the agent of choice for anticoagulating a patient with APLS?
Warfarin
At what renal function do we dose reduce Xarelto?
CrCl of 50mL/min based on actual body weight
What should the INR be to appropriately switch from warfarin to heparin?
Once the patient's INR is no longer therapeutic
Therapeutic range can vary but some typical values we see are:
On-X valve: 1.5-2
Mechanical aortic valve and DVT treatment: 2-3
Mechanical mitral valve: 2.5-3.5
How long after administrations of Lovenox and heparin is protamine indicated for reversal?
Heparin: 2-3 hours -> 1mg of protamine reverses 100 units of heparin (maximum dose: 50mg)
Lovenox: 8 hours -> 1mg of protamine reverses 1mg of Lovenox (maximum dose: 50mg)
What is one criteria that must be met for anti-Xa levels to be indicated in patient being treated with enoxaparin?
Therapy >7 Days AND:
Actual body weight >150kg or a BMI >40
CrCl <30 or on dialysis
Pregnancy
Previous failure of LMWH or UFH therapy
Adult trauma patients
What is one alternative for anticoagulation in a patient with a positive HIT panel at YNHH?
Bivalrudin
Fondaparinux
DOACs
Warfarin once the platelet count has recovered (150,00 x 2 days)
An 85 year old patient on DVT treatment with Eliquis presents with a body weight of 61kg and a serum creatinine of 2.6mg/dL. What should the dose be?
10mg BID for 7 days followed by 5mg BID
A patient is bridging to warfarin with heparin. Their goal INR is 2-3. The INR on 7/21 was 1.5 and their INR on 7/22 is 2.7. Should you discontinue heparin?
No, two consecutive INRs within the goal range are required.
What is a concern with the administration of protamine outside of the appropriate window?
Protamine can act as an anticoagulant if it does not bind to heparin or LMWH
Why do we correlate anti-Xa and PTT levels in a patient positive for lupus anticoagulant?
There is a risk for false prolongation of the PTT in patients with Lupus Anticoagulant
What is the anticoagulant of choice in a patient with cirrhosis?
Warfarin
DOACs are being used more frequently, but warfarin is still preferred in many cases as there is better monitoring in these high risk patients.