NAPLEX Study Notes: Anticoagulation & Blood Disorders
1. What anticoagulants are direct thrombin inhibitors?: IV - Argatroban,
Bi- valirudin
PO - Dabigatran
2. UFH Dosing: VTE Prophylaxis: 5,000 units SC Q8-
12H VTE Treatment: 80 units/kg IV bolus, then 18
units/kg/hr
ACS/STEMI Treatment: 60 units/kg IV bolus, then 12 units/kg/hr
Use TBW for dosing
3. What monitoring is required for UFH?: 1. Monitor aPTT or anti-XA level
- Check 6 hours after initiation and q6h until therapeutic, then every 24
hours
- aPTT therapeutic range is 1.5-2.5 x control
- Not required for prophylactic dosing
2. Monitor platelets, hgb, hct
4. Antidotes for Anticoagulants: UFH/LMWH - Protamine
- 1 mg protamine will reverse ~100 units of heparin
- Reverse the # of heparin in the last 2-2.5 hrs, max
dose 50 mg Dabigatran (Pradaxa) - Idarucizumab
(Praxbind) Apixaban/Rivaroxaban - Andexanet alfa
(Andexxa)
Warfarin - Vitamin K (Phytonadione)
5. Enoxaparin (Lovenox) Dosing: VTE Prophylaxis:
- 30mg SC Q12H or 40mg SC QD
- CrCl <30: 30mg SC QD
VTE & UA/NSTEMI Treatment:
- 1mg/kg SC Q12H or 1.5mg/kg SC QD (inpatient VTE)
- CrCl <30: 1mg/kg SC QD
STEMI Treatment
- <75: give 30mg IV bolus plus 1mg/kg SC dose
1/
, NAPLEX Study Notes: Anticoagulation & Blood Disorders
- e75 no bolus, max 5mg 1st 2 doses only. 0.75mg/kg SC Q12H
- If e75 and CrCl <30: Give 1mg/kg SC QD
6. What is monitored with LMWH?: 1. Monitor platelets, hgb, hct, SCr
- Does not required anti-Xa monitoring (more predictable)
- Anti-Xa monitoring recommended in pregnancy or with patients who
are obese,low body weight, peds, elderly or renal insufficiency
- Obtain peak anti-Xa levels 4 hours post SC dose
- When can Warfarin be restarted in HIT?: When platelets have
recovered to e150,000
- initiate at lower dose (5mg max)
- overlap with non-heparin anticoagulant for a minimum of 5 days and
until INR is within target range for 24 hours
- Argatroban can increase INR
- Bivalirudin is preferred if PCI or urgent cardiac surgery is required
- How is Eliquis dosed?: Stroke Prophylaxis: 5mg PO
BID DVT prophylaxis after knee/hip replacement: 2.5mg
BID Treatment of DVT/PE: 10mg PO BID x7 days, then
5mg PO BID
- How is Xarelto dosed?: Stroke Prophylaxis:
- 20mg PO with evening meal (CrCl >50)
- 15mg PO with evening meal (CrCl >15)
- Avoid use (CrCl <15)
- DVT prophylaxis after knee/hip replacement:
- 10mg PO x35 days (hip)
- 10mg PO x12 days
(knee) Treatment of
DVT/PE:
- 15mg PO BID x 21 days, then 20mg PO QD w/ foodHow is Savaysa
dosed?: Stroke Prophylaxis:
- CrCl >95 or <15 = DO NOT USE
- CrCl <50 = 30mg QD, CrCl >50 = 60mg QD
- Treatment of DVT/PE:
- 60mg QD, starting after 5-10 days of parenteral anticoagulation
- Oral Direct Factor Xa Inhibitor Boxed Warning: 1. Risk of hematomas
and paralysis if receiving epirual (neuraxial anesthesia)
- Edoxaban has reduced efficacy if CrCl >95
- Monitoring for Oral Direct Factor Xa Inhibitors: No monitoring for
efficacy required
- Can monitor Hgb, Hct, Scr, LFTs (edoxaban)
2/
1. What anticoagulants are direct thrombin inhibitors?: IV - Argatroban,
Bi- valirudin
PO - Dabigatran
2. UFH Dosing: VTE Prophylaxis: 5,000 units SC Q8-
12H VTE Treatment: 80 units/kg IV bolus, then 18
units/kg/hr
ACS/STEMI Treatment: 60 units/kg IV bolus, then 12 units/kg/hr
Use TBW for dosing
3. What monitoring is required for UFH?: 1. Monitor aPTT or anti-XA level
- Check 6 hours after initiation and q6h until therapeutic, then every 24
hours
- aPTT therapeutic range is 1.5-2.5 x control
- Not required for prophylactic dosing
2. Monitor platelets, hgb, hct
4. Antidotes for Anticoagulants: UFH/LMWH - Protamine
- 1 mg protamine will reverse ~100 units of heparin
- Reverse the # of heparin in the last 2-2.5 hrs, max
dose 50 mg Dabigatran (Pradaxa) - Idarucizumab
(Praxbind) Apixaban/Rivaroxaban - Andexanet alfa
(Andexxa)
Warfarin - Vitamin K (Phytonadione)
5. Enoxaparin (Lovenox) Dosing: VTE Prophylaxis:
- 30mg SC Q12H or 40mg SC QD
- CrCl <30: 30mg SC QD
VTE & UA/NSTEMI Treatment:
- 1mg/kg SC Q12H or 1.5mg/kg SC QD (inpatient VTE)
- CrCl <30: 1mg/kg SC QD
STEMI Treatment
- <75: give 30mg IV bolus plus 1mg/kg SC dose
1/
, NAPLEX Study Notes: Anticoagulation & Blood Disorders
- e75 no bolus, max 5mg 1st 2 doses only. 0.75mg/kg SC Q12H
- If e75 and CrCl <30: Give 1mg/kg SC QD
6. What is monitored with LMWH?: 1. Monitor platelets, hgb, hct, SCr
- Does not required anti-Xa monitoring (more predictable)
- Anti-Xa monitoring recommended in pregnancy or with patients who
are obese,low body weight, peds, elderly or renal insufficiency
- Obtain peak anti-Xa levels 4 hours post SC dose
- When can Warfarin be restarted in HIT?: When platelets have
recovered to e150,000
- initiate at lower dose (5mg max)
- overlap with non-heparin anticoagulant for a minimum of 5 days and
until INR is within target range for 24 hours
- Argatroban can increase INR
- Bivalirudin is preferred if PCI or urgent cardiac surgery is required
- How is Eliquis dosed?: Stroke Prophylaxis: 5mg PO
BID DVT prophylaxis after knee/hip replacement: 2.5mg
BID Treatment of DVT/PE: 10mg PO BID x7 days, then
5mg PO BID
- How is Xarelto dosed?: Stroke Prophylaxis:
- 20mg PO with evening meal (CrCl >50)
- 15mg PO with evening meal (CrCl >15)
- Avoid use (CrCl <15)
- DVT prophylaxis after knee/hip replacement:
- 10mg PO x35 days (hip)
- 10mg PO x12 days
(knee) Treatment of
DVT/PE:
- 15mg PO BID x 21 days, then 20mg PO QD w/ foodHow is Savaysa
dosed?: Stroke Prophylaxis:
- CrCl >95 or <15 = DO NOT USE
- CrCl <50 = 30mg QD, CrCl >50 = 60mg QD
- Treatment of DVT/PE:
- 60mg QD, starting after 5-10 days of parenteral anticoagulation
- Oral Direct Factor Xa Inhibitor Boxed Warning: 1. Risk of hematomas
and paralysis if receiving epirual (neuraxial anesthesia)
- Edoxaban has reduced efficacy if CrCl >95
- Monitoring for Oral Direct Factor Xa Inhibitors: No monitoring for
efficacy required
- Can monitor Hgb, Hct, Scr, LFTs (edoxaban)
2/
