Anticoagulation¶
Madeleine Turcotte
Agent | Treatment Dose | Renal Dose | Prophylaxis | Monitoring |
---|---|---|---|---|
Unfractionated heparin | 80 U/kg bolus, then 18 U/kg/hr | No change necessary | 5000 U q8h | PTT (automatic in order set) |
Enoxaparin (Lovenox) |
1 mg/kg q12h | 1 mg/kg daily | 40 mg daily or 30 mg BID |
LMWH level (anti-Xa level) Best checked 4 h after 4th dose
|
Warfarin (Coumadin) | Start 2-5mg daily and monitor INR Can consult Pharmacy
|
No change necessary |
N/A | PT/INR Use Chromogenic Factor X assay if pt has APLS |
Dabigatran (Pradaxa) | After 5 days of a parenteral AC, 150 mg BID |
Avoid use | N/A | Can test drug level if concerned (Any DOAC) |
Rivaroxaban (Xarelto) | 15 mg BID x21 d then 20 mg daily | Avoid use in CrCl<30 | 10mg QD | |
Apixaban (Eliquis) | 10mg BID x7d, then 5mg BID | VTE: No adjustment | 2.5 mg BID | A Fib: 2.5mg BID, if 2 of the following: Cr 1.5, Age > 80 Weight < 60kg |
Edoxaban (Savaysa) | After 5 days of a parenteral AC, 60 mg daily |
30 mg for CrCl 15-50 Avoid if CrCl > 95 |
Best studied option in renal dysfunction |
Additional Information¶
- VA is starting to move towards rivaroxaban and apixaban for extended
secondary thromboprophylaxis
- Write in your PADR for apixaban citing “patient uses a pillbox and cannot use dabigatran”
- Renal dysfunction: favor warfarin, apixaban or edoxaban
- Hx of GI bleed: avoid dabigatran, rivaroxaban, edoxaban (may have higher risk of GI bleed)
- Pregnancy: UFH/LMWH (other agents may cross the placenta)
Transitioning Between Anticoagulants with DOACs¶
- LMWH to Warfarin
- Warfarin and LMWH given simultaneously until INR is therapeutic for 24 hours
- Warfarin to DOAC
- Start DOAC when INR < 2.0
- DOAC to Warfarin
- High Risk DVT/PE – start LMWH or UFH, then start Warfarin
- Low to Moderate Risk DVT/PE – Start warfarin while patient on DOAC, Stop DOAC on Day 3 of warfarin therapy, Check INR on day 4
- LMWH to DOAC
- Stop LMWH and start DOAC when due for next dose of LMWH (within 2 hrs)
- DOAC to LMWH
- Stop DOAC and start LMWH when due for next DOAC dose
- UFH to DOAC
- Start DOAC when IV stopped (30 min prior to cessation if high risk for thrombosis)
- DOAC to UFH
- Start IV heparin with bolus when next DOAC dose is due
Peri-Procedural Management of Anticoagulation¶
- Temporary IVC filter indicated in pts with very recent acute VTE (within 3-4 weeks) if the procedure requires AC delay >12 hours
- For those at high risk of thromboembolism:
- Consider continuing AC for low-bleeding-risk procedures, i.e. dental procedures, cutaneous biopsy/excision, ICD placement, endovascular procedures.
- Can bridge with LMWH or heparin drip
Stop before procedure | Restart after procedure | |
---|---|---|
Warfarin | 5 days prior, check INR day of | 12 to 24 hours after |
Dabigatran | 48 hours prior (longer if CrCl 30-50 or procedure is high bleeding risk) |
1 day after (2 days if high bleeding risk) |
Rivaroxaban | ||
Apixaban | ||
Edoxaban | ||
Heparin | Stop infusion 4-5 hours prior | 24 hours after |
Enoxaparin | 12 - 24 hours prior | 24 hours after, (48-72 hours if high bleeding risk) |
Strategies for Reversal of Anticoagulation¶
Warfarin¶
- Vitamin K: onset within a few hours but takes 24-48 hrs for full effect
- Life Threatening Bleeding: Give IV Vitamin K 10 mg over 30 minutes
- Intracranial bleed, bleed with hemodynamic instability, emergent
procedure non-life threatening
- INR <5: Vitamin K not recommended
- INR 5-10: Vitamin K 1-5 mg IV or PO
- INR >10: Vitamin K 5mg PO or 5 mg IV
- Prior to surgery
- Rapid reversal INR > 5: 5mg Vit K IV (24 hours prior to procedure)
- FFP
- 15 ml/kg (i.e. 4 units/70 kg person) if need reversal <24 hrs, plus give Vitamin K
- KCentra ($$$): Contains Factors II, VII, IX, and X with Protein C,
Protein S, and heparin
- Given instead of plasma when insufficient time for plasma/Vit K to work (i.e. for life threatening hemorrhage)
- Avoid giving this in HIT
- Administer with Vitamin K
Dabigatran¶
- Idarucizumab ($$$) will reverse if prolonged thrombin time (remember to check!) – Consult Hematology
Factor Xa Inhibitors (rivaroxaban, apixaban, edoxaban)¶
- FEIBA (Factor VIII inhibitor bypassing activity) – can promote coagulation but is not a reversal agent; limited data to support use
- Consult Hematology before using; andexanet alfa (FDA approved) is not on VUMC formulary but is on the VA formulary
Last update:
2022-06-24 23:35:57