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Questions and Answers
Which of the following medications is NOT a recommended option for VTE prophylaxis?
Which of the following medications is NOT a recommended option for VTE prophylaxis?
What is the recommended dosing for Enoxaparin in a pregnant patient during her second trimester?
What is the recommended dosing for Enoxaparin in a pregnant patient during her second trimester?
For the 74-year-old male patient with renal function of 26 mL/min, which VTE prophylaxis option is most suitable?
For the 74-year-old male patient with renal function of 26 mL/min, which VTE prophylaxis option is most suitable?
Which patient characteristic is important to collect when treating VTE?
Which patient characteristic is important to collect when treating VTE?
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How long should VTE prophylaxis generally be administered postoperatively?
How long should VTE prophylaxis generally be administered postoperatively?
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What action should be taken if the INR is deemed subtherapeutic?
What action should be taken if the INR is deemed subtherapeutic?
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How often should INR be rechecked after a dose change?
How often should INR be rechecked after a dose change?
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What is the appropriate action if the INR is significantly above the therapeutic range?
What is the appropriate action if the INR is significantly above the therapeutic range?
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What is a recommended strategy for patient-specific warfarin dosing?
What is a recommended strategy for patient-specific warfarin dosing?
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What should be done if the INR is greater than 0.5 above the goal?
What should be done if the INR is greater than 0.5 above the goal?
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What is a critical instruction for administering enoxaparin?
What is a critical instruction for administering enoxaparin?
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Which of the following is NOT a sign of minor bleeding?
Which of the following is NOT a sign of minor bleeding?
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Why is it important for patients on warfarin to monitor their vitamin K intake?
Why is it important for patients on warfarin to monitor their vitamin K intake?
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What type of monitoring is required for patients taking warfarin?
What type of monitoring is required for patients taking warfarin?
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Which medication is known to increase INR when taken with warfarin?
Which medication is known to increase INR when taken with warfarin?
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Which of the following is a potential side effect of warfarin?
Which of the following is a potential side effect of warfarin?
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What is the primary therapeutic use of warfarin?
What is the primary therapeutic use of warfarin?
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What should patients do if bleeding lasts more than 10 minutes?
What should patients do if bleeding lasts more than 10 minutes?
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What is the most appropriate anticoagulation to discharge a patient after 3 days of parenteral anticoagulation?
What is the most appropriate anticoagulation to discharge a patient after 3 days of parenteral anticoagulation?
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What is the target INR range recommended for managing VTE with Warfarin?
What is the target INR range recommended for managing VTE with Warfarin?
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Which initial dosing of Warfarin is generally recommended for healthy outpatient patients?
Which initial dosing of Warfarin is generally recommended for healthy outpatient patients?
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When adjusting Warfarin dosage, why might a lower starting dose of 2.5 mg be considered?
When adjusting Warfarin dosage, why might a lower starting dose of 2.5 mg be considered?
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How frequently should INRs be monitored during the initial treatment phase of Warfarin?
How frequently should INRs be monitored during the initial treatment phase of Warfarin?
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What percentage of weekly dose changes is generally used when adjusting Warfarin dosing?
What percentage of weekly dose changes is generally used when adjusting Warfarin dosing?
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When should a patient retest their INR if there was one out of range value but the rest were stable?
When should a patient retest their INR if there was one out of range value but the rest were stable?
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What should be done if the INR rises significantly above therapy range during Warfarin management?
What should be done if the INR rises significantly above therapy range during Warfarin management?
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What factor is NOT included when assessing the weekly Warfarin dose?
What factor is NOT included when assessing the weekly Warfarin dose?
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What is the primary method recommended for monitoring INR during inpatient treatment?
What is the primary method recommended for monitoring INR during inpatient treatment?
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What is the appropriate dose of Enoxaparin for a patient with renal impairment and a CrCl of less than 30 mL/min?
What is the appropriate dose of Enoxaparin for a patient with renal impairment and a CrCl of less than 30 mL/min?
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Which medication requires parenteral anticoagulation for 5 days before starting its oral formulation?
Which medication requires parenteral anticoagulation for 5 days before starting its oral formulation?
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What is the purpose of monitoring Anti-Xa levels after administering Dalteparin?
What is the purpose of monitoring Anti-Xa levels after administering Dalteparin?
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What is the IN range for a patient on Warfarin for DVT/PE treatment?
What is the IN range for a patient on Warfarin for DVT/PE treatment?
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Which of the following indicates that a patient should avoid Dabigatran?
Which of the following indicates that a patient should avoid Dabigatran?
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After discontinuing IV Heparin, when should Apixaban be initiated?
After discontinuing IV Heparin, when should Apixaban be initiated?
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What is the recommended dose of Edoxaban for patients weighing less than 60 kg?
What is the recommended dose of Edoxaban for patients weighing less than 60 kg?
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Which of the following can be used as a specific reversal agent for Warfarin?
Which of the following can be used as a specific reversal agent for Warfarin?
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Which anticoagulant does not require any dose adjustments for patients with renal impairment?
Which anticoagulant does not require any dose adjustments for patients with renal impairment?
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If a patient has experienced a PE and is being discharged on Warfarin, what is the minimum therapeutic INR required?
If a patient has experienced a PE and is being discharged on Warfarin, what is the minimum therapeutic INR required?
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Study Notes
VTE Prophylaxis Options
- Eliquis 2.5 mg by mouth twice daily
- Rivaroxaban 10 mg PO QD
- Enoxaparin 40 mg subcut daily OR 30 mg subcut every 12 hours
- Administer > 12 hours pre- or postoperatively
- Sub Q 5000 units every 8-12 hours
Recommended Duration of Prophylaxis
- Duration of prophylaxis for patients depends on individual risk factors.
VTE Medications for Specific Patients
-
26-year-old female, 26 weeks 4 days pregnant: Sub q unfractionated heparin
- First trimester: 5,000-7,500 units every 12 hours
- Second trimester: 7,500-10,000 units every 12 hours
- Third trimester: 10,000 units every 12 hours
- 74-year-old male, BMI 28 kg/m^2, renal function 26 mL/min: Consider medications with renal dose adjustments.
- 48-year-old patient, BMI 62.7 kg/m^2: Higher risk for VTE, consider higher-dose options.
Treatment of VTE
- Collect patient characteristics, history, current medications, and objective data.
- Assess hemodynamic instability, particularly in cases of pulmonary embolism (PE).
- Plan pharmacotherapy regimen, considering the need for a reversal agent.
Enoxaparin (Lovenox)
- 1 mg/kg subcut every 12 hours OR 1.5 mg/kg subcut every 24 hours
- Renal impairment:
- CrCl < 30 mL/min: 1 mg/kg subcut daily
- Dialysis: not recommended
- Overlap considerations: Warfarin, dabigatran, edoxaban.
- Dose based on actual body weight.
Dalteparin (Fragmin)
- 200 units/kg subcut every 24 hours OR 100 units/kg subcut every 12 hours
- No renal dose adjustments.
- Monitor Anti-Xa levels 4 hours post-dose.
Direct Oral Anticoagulants (DOACs)
- Dabigatran (Pradaxa): 150 mg by mouth twice daily, avoid in elderly patients with bleeding risk.
- Apixaban (Eliquis): 10 mg by mouth twice daily for 7 days, then 5 mg twice daily.
- Rivaroxaban (Xarelto): 15 mg by mouth twice daily with food for 21 days, then 20 mg daily with food.
-
Edoxaban (Savaysa):
- Weight > 60 kg: 60 mg by mouth daily
- Weight < 60 kg: 30 mg by mouth daily
- Consider alternative agents if CrCl > 95 mL/min.
Warfarin (Coumadin)
- DVT/PE goal INR range: 2-3
- Overlap with parenteral anticoagulant for at least 5 days and 2 therapeutic INRs.
Monitoring: Parenteral Agents
- Baseline: CBC, serum creatinine, coagulation studies
- Ongoing: Signs and symptoms of bleeding
- Every 1-3 days: CBC
- For IV Unfractionated Heparin (UFH), monitor aPTT or Anti-Xa levels.
Specific Reversal Agents
- Heparin & LMWH: Protamine
- Dabigatran (Pradaxa): Idarucizumab (Praxbind)
- Apixaban (Eliquis) & Rivaroxaban (Xarelto): Andexanet Alfa (Andexxa)
- Warfarin: Vitamin K
Nonspecific Reversal Agents
- Fresh frozen plasma
- Prothrombin Complex Concentrate (PCC4) (Kcentra)
- Recombinant Factor VII
Discharging Options from IV Heparin
- LMWH, apixaban, or rivaroxaban: Start within 2 hours of discontinuing IV heparin.
- Dabigatran or edoxaban: Start within 2 hours of discontinuing IV heparin, give parenteral therapy for 5-10 days.
- Warfarin: Start at least 5 days and 2 therapeutic INRs after discontinuing IV heparin.
Discharging Options from LMWH
- Apixaban or rivaroxaban: Start at the next dosing interval.
- Dabigatran or edoxaban: Give parenteral therapy for 5-10 days, start at the next dosing interval.
- Warfarin: At least 5 days and 2 therapeutic INRs after discontinuing LMWH.
Patient Case: Pregnant Patient with PE
- The most appropriate anticoagulant for discharge is Enoxaparin (E). DOACs are contraindicated in pregnancy.
Warfarin Management
- Clinical Monitoring: Frequent INR checks, Time in Therapeutic Range (TTR).
- Interpreting INR: Subtherapeutic, therapeutic, supratherapeutic.
Initial Dosing
- CHEST guidelines recommend 10 mg by mouth daily for 2 days in healthy outpatients.
- Consider lower doses: 5 mg daily, or 2.5 mg daily for patients with renal dysfunction, interacting medications, liver disease, high bleeding risk, older age.
Adjusting Warfarin During Initiation
- Frequent INR checks: daily inpatient, every 2-3 days outpatient.
- Steady INR increase; Large jumps may require holding or decreasing the dose; Slow response requires an increased dose.
Assessment of Maintenance Phase Warfarin
- Assess weekly dose, do not include boosts or holds.
- Consider 5-10% dose changes.
Adjustment of Warfarin Dosing
- Assess weekly dose.
- If INR is stable with one out-of-range INR, consider continuing the current regimen.
- Adjust dose if there's a clear reason for the INR change.
Warfarin Nomogram Example
- Subtherapeutic: Boost x 0-1 days, increase dose by 5-10%.
- Therapeutic: Continue the same dose.
- Supratherapeutic: Hold x 0-1 days, decrease dose by 5-10%. Hold for 1 day if INR is 0.5 or more above goal; consider holding until the rechecked INR is therapeutic before restarting at a lower dose.
- INR > 10: Oral vitamin K (see reversal section).
Warfarin Dosing Clinical Pearls
- Patient-specific dosing
- Single strength tablets
- Stick with 5-10% changes based on weekly dose
- Consider holding warfarin if INR is > 0.5 above goal; hold for 1 dose. If INR is > 1 above goal, hold until the INR decreases.
Monitoring Recommendations
- After dose change, recheck INR in 1-2 weeks.
- After 1 therapeutic INR on a stable dose, recheck in 2 weeks.
- After 2 therapeutic INRs on a stable dose, recheck in 4 weeks.
- Continue monitoring monthly.
Enoxaparin Education
- Inject the exact prescribed dose
- Inject at the same time each day
- Hold the skin fold throughout the injection
- Do not rub the area after injection
- Rotate injection sites
- Never inject into the muscle.
Warfarin Education
- Warfarin helps prevent clotting and for patients with previous strokes, prevents another stroke.
- Reason for taking warfarin: Prevents new clots from forming.
- Take it at the same time each day; do not skip doses.
- INR checks are needed to monitor the medication.
- Side effects: Bruising/bleeding, skin necrosis, or purple toe syndrome.
Warfarin Education - Signs and Symptoms of Bleeding
- Minor Bleeding: Gum bleeding, knicks when shaving, nosebleeds, bruising, excessive menstrual flow.
- Major Bleeding: Dark brown or red urine, black tarry stools, bright red or coffee grounds vomit.
- Medical Attention: Bleeding lasting >10 minutes, falls/hits head.
Warfarin Education - Diet
- Focus on consistent Vitamin K intake.
- Foods high in Vitamin K: Kale, spinach, Brussel sprouts, collard greens, asparagus, avocado, soybeans, prunes.
Warfarin Education - Drug-Drug Interactions (DDIs)
- Agents that increase INR: Fluconazole (Azoles), Amiodarone, Bactrim (Sulfonamides), Flagyl
- Agents that decrease INR: Fluoroquinolones, Phenytoin, Thyroid hormones, Cholestyramine, cholesterol-lowering agents, St.
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