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