-
Heparin Brand/Route
- heplock
- hepflush
- *given SC/IV
-
Enoxaparin brand/class
lovenox; SC (LMWH)
-
fragmin brand/class
delteparin; SC (LMWH)
-
innohep generic/class/route
tinzaparin (LMWH); SC
-
dabigatran brand/route
pradaxa; PO DTI
-
lepirudin brand/route/class
Refludan; SC/IV DTI
-
Bivalrudin brand/class/route
Angiomax; IV direct thrombin inhibitor
-
fondaparinux brand/class/route
arixtra; SC factor Xa inhibitor (direct)
-
apixaban brand/class/route
eliquis; PO (direct factor Xa inhibitor)
-
Rivaroxaban brand/class/route
xarelto; PO (direct factor Xa inhibitor)
-
IND for UFH
prophylaxis and treatment of thromboembolic disorder
-
precautions for UFH
- pts who are at high risk for bleeding
- pts treated concomitantly w platelet inhibitors
-
contraindications of UFH
- hypersensitivity
- severe thrombocytopenia
- <50,000/mm3
- uncontrolled active bleeding
- intracranial hemorrhage
-
UFH treatment of venous thromboembolism
- IV Heparin- 80U/kg bolus and 18U/kg/hr infusion
- SC Heparin-
-
UFH treatment of angina and NSTEMI
UFH bolus of 60-70U/kg followed by 12-15U/kg/hr infusion
-
UFH treatment of ACS when heparin is given in conjunction with fibrinolytic agent
60U/kg bolus dose and then 12U/kg/hr infusion
-
what is aPTT
- activated partial thromboplastin time
- intrinsic pathway of clotting cascade
-
UFH monitoring
- aPTT
- platelet
- hemoglobin/hematocrit
- bleeding
-
IV heparin dose adjustment for PTT >120
- bolus dose: none
- stop infusion: 60 min
-
IV heparin dose adjustment for PTT 96-119
- bolus dose: none
- stop infusion: 30 min
-
when do you repeat initial bolus dose for PTT time
when its <50
-
duration of UFH
7-10 days
-
when do you stop Heparin tx
when >5 days and until INR is therapeutic
-
when do you discontinue UFH <5 days
increased risk for recurrent thrombosis
-
bridge therapy of Heparin
initiate warfarin on day 1 of Heparin
-
Heparin AE
- thrombocytopenia
- osteoporosis
- hyperkalemia
- hypersensitivity reaction
- elevated liver enzymes
- bleeding
-
how long does it take for thrombocytopenia to occur
5-14 days after beginning of therapy
-
how to treat thrombocytopenia
use direct thrombin inhibitors
-
if pt has thrombocytopenia what do you not rechallenge the pt with
UFH or LMWH
-
Heparin drug interactions
- drugs which affect platelet function
- thrombolytic agents
- warfarin
- penicillins (parenteral)
-
how to reverse Heparin
protamine sulfate (1mg will nueutralize 100U)
-
AE of protamine sulfates
- hypotension
- bradycardia
- sufla allergy reactions
-
IND for LMWH
prevention and treatment of venous thromboembolism
-
adv of LMWH compared to UFH
- fewer deaths, major hemorrhage, recurrent VTE
- no aPTT monitoring
- home treatment
-
precautions for LMWH
- hx of major bleeding
- concurrent use of antiplatelet and antithrom
- congenital bleeding disorder
-
contraindication to LMWH
- hypersensitivity to enoxaparin
- severe thrombocytopenia
- hypersensitivity to pork
- active major bleeding
-
when is LMWH lab monitoring necessary
- obese
- renal insufficiency
-
reversal of LMWH
- protamine sulfate
- if last dose w/in 8hrs=1mg per 1mg lovenox
- if last dose > 8hr= 0.5mg per 1mg lovenox
-
LMWH AE
- CNS
- dermatologic; erythema, bruising
- hemorrhage, thrombocytopenia
- ALT/AST increased
- local pain, irritation
-
duration of therapy for LMWH
at least 5 days and until INR is therapeutic
-
monitoring for LMWH
- baseline:
- Hct
- INR
- renal function
- platelet count
-
Warfarin strengths
1, 2, 2.5, 3, 4, 5, 6, 7.5, 10
-
benefits of warfarin
decrease risk of stroke by 35% in pt with afib
-
warfarin limitations
- slow onset
- genetic variation in metabolism
- multiple food and drug interactions
- narrow therapeutic index
-
IND for coumadin
- prophylaxis and treatment of DVT and PE
- a fib with risk factor for embolism
- after mechanical heart valve replacement
- after MI
- after stroke
- prolonged immobility due to surgery
-
warfarin Contraindications
- hypersensitivity to warfarin
- hemorragic tendencies
- recent or potential surgery
- high risk fall
- uncontrolled HTN
- hepatic disease
- pericarditis or pericardial effusion
- alcoholism
- pregnancy
-
factors affecting warfarin response
- genetics
- pts with cyp450 2c9 mutation gene
- hereditary resistance to warfarin
- environmental
- drugs
- diet
- disease states (hepatic dysfunction potentiates warfarin response)
-
started dose for warfarin
5-10mg for the first 1 or 2 days
-
pts with starting dose < 5mg
- elderly pts
- pts who are debilitated, malnourished
- pts with CHF
- pts with liver disease
- pts who had recent major surgery
- pts who are taking medications know to increase sensitivity to warfarin (amiodarone)
-
-
warfarin dose adjustments when INR is outside therapeutic range
- calculate weekly warfarin dose
- adjust by up or down increments of 5-20%
-
when do you follow up on INR
in 1-2 weeks
-
warfarin drug interactions that decrease absorption
- cholestyramine
- colestipol
- sucralfate
-
Warfarin DI increased synthesis of clotting factors
vitamin K
-
Warfarin drug interactions that reduced catabolism of clotting factors
-
Warfarin DI that induce warfarin metabolism
- chronic alcohol use
- nafcillin
- dicloxacillin
- carbamazepine
- rifampin
- primidone
- phenytoin
- barbiturates
-
warfarin DI that impair vitamin K production by GI flora
board spectrum antibiotics
-
warfarin DI that decreases synthesis of clotting factors
- cefotetan
- cefmetazole
- cefoperazone
- vitamin E
-
Warfarin DI that inhibits metabolism
- acute alcohol use
- allopurinol
- amiodarone
- azole antifungals
- celecoxib
- cimetidine
- disulfiram
- fluoroquinolone
- isoniazid
- macrolide
- metronidazole
- omeprazole
- phenytoin
- quinidine
- rofecoxib
- SSRIs
- statins (EXCEPT pravastatin)
- sulfa antibiotics
-
warfarin DI that increase bleeding risk
- asa
- clopidogrel/ticlopidine
- COX 2 inhibitors
- NSAIDS
- GP IIb/IIIA antagonist
-
foods that are rich in vitamin K
- mayo
- canola, salad, soy bean oil
- broccoli
- brussel sprouts
- cabbage/lettuce/kale
- collard greens/mustard greens
- spinach
- watercress
|
|
