Anticoagulation Cheat Sheet Reversal Agent Heparin None Activated Charcoal1 Enoxaparin3 Tinzaparin3 Dalteparin3 Fondaparinux Argatroban √ Bivalirudin √ Dabigatran √ Rivaroxaban Apixaban √ √ Edoxaban √ Betrixaban √ √ √ Warfarin Monitoring Heparin Enoxaparin Tinzaparin Dalteparin Fondaparinux Argatroban Bivalirudin Dabigatran10 Rivaroxaban11 Apixaban11 Edoxaban11 Betrixaban11 Warfarin Dabigatran Rivaroxaban Apixaban 1 aPTT Anti-Xa PT INR ACT √ √ √ √ √ √ √ √ √ √ √ Drug Interactions CI w/ strong P-gp inducers/ inhibitors15 CI w/ strong CYP3A4 and/or P-gp inducers/inhibitors15 Warfarin Betrixaban Reduce betrixaban dose w/ strong P-gp inhibitors Dosing depends on route and time since last dose of Heparin Not complete 4 Hemodialysis causes prolonged activity 5 FFP is unconcentrated factors II/VII/IX/X, while 4PCC is concentrated factors II/VII/IX/X Risk of obstetric hemorrhage and/or emergency delivery risk 7 All pending bleed risk of surgery, hold longer for higher risk 8 Hold time may be longer depending on renal function 9 INR is gold standard for monitoring, hepatic function may impact 10 Ecarin clotting time (ECT) and thrombin time (TT) may be useful but no utility in monitoring efficacy Unreliable effect on PT/INR/aPTT, so not used to monitor therapy SSRIs Tinzaparin SNRIs Dalteparin Garlic Fondaparinux Ginseng Argatroban Gingko Herbals Ginger Rivaroxaban Feverfew Saw Palmetto Edoxaban Willow Bark Betrixaban Use in patients undergoing spinal/epidural anesthesia or spinal puncture increased risk of spinal/epidural hematoma and paralysis Caution in elderly (increased risk of death in elderly with renal insufficiency Caution in patients sensitive to pork products Safe in HIT; LMWH is not Can falsely elevate INR, 2 mcg/kg/min as continuous infusion to treat HIT Must go through stomach to be fully absorbed (NG, OG, and G tubes); significant AUC decrease if admin via ND, NJ, IJ, or GJ tubes Cannot be used for afib in CrCl >95 mL/min due to risk of treatment failure Recommended duration of therapy 35-42 days Heparin-Induced Thrombocytopenia (HIT) & Thrombosis (HITT) Mechanism Onset Findings I Direct interaction of platelets and heparin, usually leading to sequestration or clumping 2 Days Mild, transient thrombocytopenia, usually resolved within 4 days of discontinuation Platelet factor 4 (PF4) binds 4-10 with heparin and becomes Days immunogenic, leading to Unlesshttps://www.coursehero.com/file/83333765/tldr-Anticoag-Cheat-Sheet-v11pdf/ antibodies present from recent exposure heparin-PF4 antibodies PF4-heparin antibodies, risk of thrombosis, moderate thrombocytopenia, resolves 4-10 days after discontinuation, antibodies gone within 2-3 months Child-Pugh is specific set of criteria involving objective (PT/INR, Tbili, albumin) and subjective (encephalopathy, ascites) data, Class C can also be called severe hepatic impairment 13 See pharmacy times article by BD regarding data and recommendations for NOACs (actual patients on HD or w/ renal failure excluded) 14 Consider lower starting dose for low albumin (highly protein bound), also This study source downloaded 100000752467928 Vitamin K-dependent clottingwas factors (II, VII, IX, X) by synthesized in liver and liver failure may decrease levels Dose recommendations vary for moderate inhibitors/inducers 16 NOACs NSAIDs All LMWH Type 12 15 Drugs If last dose within 2 hrs 3 11 Other Agent(s) Protamine2 Antiplatelets Anything affecting 2C9, 3A4, Vitamin K, bleeding risk (and the rabbit hole goes down, down down…) 2 6 Pregnancy Category Drug Classes Heparin Hemodialysis AT-3 Inhibitors Enoxaparin Partial Heparin Tinzaparin Dalteparin 2 Enoxaparin Protamine B Fondaparinux Tinzaparin Argatroban 2 4 Dalteparin Protamine Bivalirudin Fondaparinux 4 Apixaban Edoxaban DTIs 4PCC possibly Dabigatran C ~20% Argatroban effective Rivaroxaban6 Bivalirudin 20% Warfarin X Dabigatran 25% Hold for Procedure7 Direct Xa Inhibitors Heparin 4-6 hr Idarucizumab 65% [PraxBind] Enoxaparin Rivaroxaban Tinzaparin 12-24 hr Apixaban Dalteparin 4PCC possibly Edoxaban Dabigatran effective 25% Rivaroxaban 24-72 Betrixaban hr8 Apixaban Vitamin K Antagonists Edoxaban Vitamin K, FFP, 5 9 4PCC Warfarin Warfarin 5 Days Drug Renal Adjustment Hepatic Adjustment12 Heparin None None Enoxaparin <30mL/min, CI in HD None Tinzaparin <30/mL/min, no specific dose suggested None Dalteparin <30 mL/min, by anti-Xa levels None Fondaparinux <50 mL/min, CI <30 mL/min Use with caution Argatroban None Consider lower initial dose Bivalirudin <30 mL/min, CAN be given in HD None Dabigatran <30 mL/min, Avoid in HD None Rivaroxaban Afib <50 mL/min, DVT <30 mL/min, Avoid in HD Avoid in Child-Pugh B Apixaban 2 or More: SCr ≥ 1.5, Age ≥ 80yo, Wt ≤ 60 kg13 Avoid in Child-Pugh C <50 mL/min, Avoid in HD Edoxaban Avoid in Child-Pugh B Do not use for afib if CrCl >95 mL/min Betrixaban <30 mL/min, decrease dose by 50% Not recommended Warfarin None No specific adjustment14 Clinical Pearls Synergistic Bleed Risk Heparin Caution in patients sensitive to pork products Anticoagulants Andexanet alfa II from CourseHero.com on 09-15-2022 17:37:08 GMT -05:00 16 Coagulation Cascade Drug Classes Heparin LMWH Fondaparinux DTIs Direct Xa Inhibitors Vitamin K Antagonists Drug Heparin Enoxaparin1 Dalteparin1 Bivalirudin STEMI NSTEMI/UA Start: 60 U/kg IV x1 Maintenance: 12 U/kg/hr IV, adjust to target aPTT or anti-Xa <75 yo: 1 mg/kg SC q12h ≥75 yo: 0.75 mg/kg SC q12h UA & non-Q-wave MI: 1 mg/kg SC q12h UA & non-Q-wave MI: 120 IU/kg SC q12h (max 10,000 IU) For PCI: consider extending PTCA (no HIT): 0.75 mg/kg IV duration of infusion post- bolus, 1.75 mg/kg/hr IV infusion procedure up to 4 hrs for duration of procedure Drug VTE ppx Heparin Enoxaparin Dalteparin Fondaparinux Dabigatran Rivaroxaban Apixaban Betrixaban 5000 U SC q8-12h2 40 mg SC Qdaily2 5000 IU SC Qdaily 1 40 mg SC Qdaily 5000 IU SC Qdaily2 2.5 mg SC Qdaily 3 Argatroban Bivalirudin 0.75 mg/kg IV bolus, 1.75 mg/kg/hr IV infusion for duration of procedure 30 mg SC q12h 2.5 mg SC Qdaily 5 10mg PO Qdaily 2.5mg PO BID Drug Heparin Enoxaparin Hip Replacement VTE ppx 30 mg SC q12h or 40mg SC Qdaily 5000 IU SC Qdaily3 2.5 mg SC Qdaily 110mg PO day 1, then 220 mg PO BID 10mg PO Qdaily 2.5mg PO BID VTE tx 80 U/kg IV x1 then 18 U/kg/hr IV, adjust to target aPTT or anti-Xa3 Inpatient: 1mg/kg Q12h or 1.5mg/kg SC Qdaily Outpatient: 1 mg/kg SC q12h Tinzaparin 175 anti-Xa IU/kg BW SC Qdaily (max 18,000 IU) Dalteparin VTE in patients with cancer (max 18,000 IU): Month 1: 200 IU/kg SC Qdaily Months 2-6: 150 IU/kg SC Qdaily Fondaparinux Body weight <50 kg: 5 mg SC Qdaily Body weight 50-100 kg: 7.5 mg SC Qdaily Body weight >100 kg: 10 mg SC Qdaily with aspirin (ASA) dosing recommendations change for obese patients Varies by patient/institution/provider 4 This study source was downloaded by 100000752467928 from CourseHero.com To prevent recurrence 5 Canadian labeling for knee replacement 6 For stroke prevention 7 Older devices (caged ball, tilting disc) may require 2.5-3.5 target 8 Left ventricular assist device https://www.coursehero.com/file/83333765/tldr-Anticoag-Cheat-Sheet-v11pdf/ 9 Can be tighter and lower, depends on institution and patient 2 Heparin PCI Planned GP IIb/IIIa No GP IIb/IIIa Prior 2000-5000 U IV prn, 2000-5000 U IV prn, Anticoag target ACT 200-250 target ACT 250-350 No Prior 50-70 U/kg IV x1, 70-100 U/kg IV x1, Anticoag target ACT 200-250 target ACT 250-350 Patients w/ or at risk for HIT: 25 mcg/kg/min w/ bolus of 350 mcg/kg via large bore IV over 3-5 min Abdominal Surgery VTE ppx Knee Replacement VTE ppx 150mg PO BID4 20mg PO Qdaily with food4 2.5mg PO BID4 160mg PO day 1, then 80mg Qdaily Drug Non-valvular Afib6 Dabigatran 150 mg PO BID Rivaroxaban 20 mg PO qdaily w/ PM meal Apixaban 5 mg PO BID Edoxaban 60 mg PO Qdaily Warfarin Indication Target INR VTE ppx / tx 2-3 Non-Valvular Afib6 7 Mechanical Valve Aortic: 2-3 , Mitral/Both: 2.5-3.5 Bioprosthetic Valve Mitral: INR 2-3 LVAD8 INR 2-39 Drug Dabigatran 150 mg PO BID (after 5-10 days parenteral anticoagulation) Rivaroxaban on 09-15-2022 15 mg 17:37:08 PO BID GMT with -05:00 food for first 21 days, then 20 mg PO Qdaily w/ food Apixaban 10mg PO BID x7d, then 5mg PO BID Edoxaban 60mg PO QDaily (after 5-10 days parenteral anticoagulation) Antiplatelet Cheat Sheet Drug Renal Adjustment Hepatic Adjustment2 Hold for Procedure4 Pregnancy Category 1 Aspirin Avoid in CrCl <10 mL/min Clopidogrel Avoid in severe Aspirin C5 5 Days impairment Ticagrelor Ticagrelor Dipyridamole Prasugrel None but not studied3 Prasugrel 5-7 Days None Clopidogrel Clopidogrel Use with caution Aspirin 7 Days B Prasugrel Abciximab Eptifibatide Eptifibatide Reduce at CrCl <50 mL/min None Hemodialysis? Tirofiban Reduce at CrCl <60 mL/min Tirofiban Eptifibatide CI if on dialysis 6 Ticagrelor Monitoring Can be removed C Tirofiban For overdose: respiratory alkalosis followed by via hemodialysis Abciximab Aspirin metabolic acidosis, monitor acid-base balance Drug Interactions Dipyridamole Monitor hepatic enzymes Caution with renin-angiotensin-aldosterone Prasugrel Monitor for potential TTP system affecting drugs and highly proteinAspirin 7 Ticagrelor Monitor serum uric acid, SCr, s/s of dyspnea bound drugs (phenytoin/valproic acid) Abciximab Eptifibatide Tirofiban Monitor platelet count, aPTT and ACT Clopidogrel Avoid strong 2C19 inhibitors, caution with 2C9 substrates Monitor platelet count, H/H, aPTT Ticagrelor CI with ASA > 81 mg Clinical Pearls Aspirin Children or teenagers with certain viral infections may develop Reye’s syndrome Clopidogrel 2C19 poor metabolizers have diminished response, but no dosing guidance Prasugrel CI in patients with prior TIA or stroke Ticagrelor ONLY ADP inhibitor that binds reversibly to platelets (competitive antagonist), in case of a bleed, ticagrelor may inhibit new platelets that are infused Eptifibatide CI if major surgery in preceding six weeks, stroke in 30 days or prior hemorrhagic stroke, bleeding diathesis or internal bleeding in last 30 days, severe uncontrolled hypertension, renal dialysis dependency Tirofiban CI if active internal bleeding or bleeding diathesis in last 30 days, history of ICH/ ICN/AV malformation/aneurysm, thrombocytopenia on drug, stroke in 30 days or prior hemorrhagic stroke, major surgery or severe physical trauma in last month, aortic dissection, severe HTN, acute pericarditis Drug Classes COX Inhibitor Aspirin PDE Inhibitor Dipyridamole P2Y12 Inhibitor Clopidogrel Prasugrel Ticagrelor GPIIb/IIIa Inhibitor Abciximab Eptifibatide Tirofiban 1 Manufacturer's recommendation to avoid using it for the purposes of analgesia/anti-inflammatory, but for antithrombotic purpose in patients with severe renal dysfunction benefits outweigh the risks so still used 2 Child-Pugh is specific set of criteria involving objective (PT/INR, Tbili, albumin) and subjective (encephalopathy, ascites) data, Class C can also be called severe hepatic impairment 3 No dosing adjustment needed for Child-Pugh Class A and B, not studied in Child-Pugh Class C 4 All pending bleed risk of surgery, hold longer for higher risk 5 Category D for full dose in 3rd trimester, recommendations on low dose vary for some condition-specific high risk patients 6 For all antiplatelets, monitor for thrombocytopenia 7 Signs and symptoms Drug Classes Aspirin PDE Inhibitor P2Y12 Inhibitor GPIIb/IIIa Inhibitor This study source was downloaded by 100000752467928 from CourseHero.com on 09-15-2022 17:37:08 GMT -05:00 https://www.coursehero.com/file/83333765/tldr-Anticoag-Cheat-Sheet-v11pdf/ Powered by TCPDF (www.tcpdf.org)