Anticoagulation%20ACCP%20guidelines%202012

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AnticoagulationACCP guidelines 2012

• Megan Chan, PGY-2
• UHCMC

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Coumadin

• Inhibits the cyclic interconversion of Vit K in
  the liver ? decrease activation of factors
  2,5,9,10
• During 1st 2-3 days of initiation, can be
  hypercoagulable 2/2 coumadins effects on Protein
  C S
• Typically 5mg daily
• If outpt can do 10mg x2 day loading dose
• Lower dose in elderly, liver dz, poor nutritional
  status, HF

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INR monitoring as Outpatient

• 1st check is after 2-3 doses
• Then 2x/wk until INR therapeutic
• Then weekly
• Then every other week then monthly
• Then q3 months if has had 3 months of consistent
  results
• If INR not in desired range can increase or
  decrease by 5-20 of total weekly dose

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http//www.aafp.org/afp/2013/0415/p556.pdf
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Unfractionated Heparin

• Works by binding to antithrombin to inactivate
  thrombin (Factor IIa) and Factor Xa
• Also prevents growth and potential propagation of
  clots
• Half life 30mins to 2 hours
• Risk of HIT
• Plts decrease by gt50 or are lt150K after
  initiation of heparin
• Usually 5-14 days after initation

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LMWH

• Enoxaparin (Lovenox), Dalteparin (Fragmin)
• Increased affinity to Factor Xa relative to
  thrombin
• Therapeutic dosing 1mg/kg q12 hrs or 1.5mg/kg
  once a day
• Avoid in pts with CrCl lt30 mL/min and in pts with
  HIT
• Half life 3-6 hours

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Fondaparinux (Arixtra)

• Specific only to Factor Xa thus low risk for HIT
• Recommended for general surgery prophylaxis in
  pts have contraindications to LMWH
• SubQ injection
• Half life 18 hours

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Bivalirudin (Angiox)

• Reversible direct thrombin inhibitor
• Used here at UH for pts you suspect or have HIT
• Continuous Drip

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Dabigatran (Pradaxa)

• Direct thrombin inhibitor
• PO med FDA approved in 2010
• Can be used for Afib stroke/embolism prevention
• 150mg BID, adjust for decreased CrCl
• Pros no monitoring or overlap needed, fewer
  drug/food interactions
• Cons Short half-life (12-17 hrs), no antidote
  for reversal

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Rivaroxaban (Xeralto)

• Direct factor Xa inhibitor
• PO med FDA approved 2011
• Indications
• Tx of DVT/PE reduce risk of recurrence
• DVT prevention in knee/hip replacement surgery
• Dosing
• DVT prophylaxis 10mg daily
• Tx DVT or PE 15mg BID x 21 days then 20mg daily
• Afib 20 mg daily
• Adjust for lower CrCl
• Half life 5-9 hours

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Apixaban (Eliquis)

• Factor Xa inhibitor
• PO med FDA approved in 2012
• Indicated for Afib related stroke or embolism
  prevention
• Dosing
• Typically 5mg BID
• lower for elderly, low body weight, CKD
• Half life 12 hrs

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  Dabigatran1 (Pradaxa) Rivaroxaban2 (Xarelto) Apixaban3 (Eliquis) Edoxaban4 (SavaysaTM)
Time to peak effect 1 hour (empty stomach)   Manufacturer requires 5-10 days of parental anticoagulation prior to initiation for treatment of DVT/PE 2-4 hours 3-4 hours 1-2 hours   Manufacturer requires 5-10 days of parental anticoagulation prior to initiation for treatment of DVT/PE
Switch from UFH Stop infusion and start dabigatran at the same time Stop infusion and start rivaroxaban at the same time Stop infusion and start apixaban at the same time Stop infusion and start edoxaban 4 hours later
Switch from LMWH or other NOAC Start dabigatran 0-2 hours prior to next scheduled dose of LMWH/NOAC and omit dose of LMWH/NOAC Start rivaroxaban 0-2 hours prior to next scheduled evening dose of LMWH/NOAC and omit dose of LMWH/NOAC Start apixaban at the same time as next scheduled dose of LMWH/NOAC and omit dose of LMWH/NOAC Start edoxaban at the same time as next scheduled dose of LMWH/NOAC and omit dose of LMWH/NOAC
Switch from warfarin Stop warfarin and start dabigatran once INR lt2.0 Stop warfarin and start rivaroxaban once INR lt3.0 Stop warfarin and start apixaban once INR lt2.0 Stop warfarin and start apixaban once INR lt2.5
Credits Sarah Dickey, Pharm D Louis Stokes
Cleveland VAMC
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VTE

• Tx initiation Coumadin Heparin/Fondaparinux
• At least 5 days overlap and until pts INR is at
  least 2.0 for 2 consecutive days
• Rivaroxaban approved for tx of DVT or PE
• LMWH best for anticoagulation in those with solid
  tumor-related VTE
• ½ the risk for recurrent VTE than Coumadin in
  those with malignancy-related VTE, no effect on
  mortality

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Treatment course for VTE

• 1st provoked DVT or PE 3 months
• 1st unprovoked DVT or PE
• 3-6 months if low risk for bleeding, then
  evaluate risk-benefit ratio for extended therapy.
• 3 months if high risk for bleeding
• 1st VTE unprovoked PE
• Life long if low risk bleeding
• 3 months if high risk for bleeding
• 2nd unprovoked DVT or PE
• Life-long if low-moderate risk bleeding
• 3 months if high risk bleeding
• Recurrent lifelong therapy
• PE with active cancer life long therapy
• Catheter related 3 months after catheter removed

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Non-valvular Afib

• CHA2DS2VASC
• CHF, HTN, Age 65-74 1 vs 75 2, DM, Stroke/TIA,
  Vascular dz
• Coumadin, Dabigatran (Pradaxa) Apixaban
  (Eliquis)
• Afib Stable CAD (no ACS in past year)coumadin
  alone gt coumadin ASA
• Intermediate-High risk Afib with ACS
  anticoagulant single antiplatelet for 12
  months
• Low risk Afib with ACSdual antiplatelet therapy
• High risk Afib with stent placementtriple
  therapy (anticoagulant, ASA, plavix) for at least
  1 month of bare metal, 3-6 months for
  drug-eluting ? anticoagulant single
  antiplatelet
• Low-Intermediate risk Afib with stent
  placementdual antiplatelet therapy gt triple
  therapy for 12 months

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Cardioversion

• If Afib/Aflutter gt48 hrs or unknown duration,
  anticoagulate for 3 weeks prior 4 weeks post
  cardioversion

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Prosthetic valves

• INR goals
• Mechanical aortic valve 2.0-3.0 ASA
• Mechanical mitral valve 2.5-3.5 ASA
• Mechanical aortic mitral valve 2.5-3.5 ASA

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Hx of Noncardioembolic Ischemic Stroke or TIA

• Plavix 75mg daily OR
• ASA/ER dipyridamole 25mg/200mg BID OR
• ASA (75-100mg daily)
• Cilostazole 100mg BID
• Stroke/TIA Afib
• Dabigatran 150mg BID gt Coumadin gt ASA Plavix
• Often bridge

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Pre-Op/Post-Op

• Warfarin should be stopped 5 days before major
  surgery and restarted 12-24 hrs post-op
• Can bridge with LMW heparin for pts with high
  risk of thromboembolism
• Restart LMWH 24 hrs after

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CABG

• Continue ASA
• Stop plavix 4 days before surgery
• If recently had a stent, would defer surgery for
  at least 6 weeks after placement of bare-metal
  sent or at least 6 months after placement of
  drug-eluting stent. If need emergently, then
  continue dual antiplatelet therapy.

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References

• http//www.aafp.org/afp/2013/0415/p556.html
• http//journal.publications.chestnet.org/pdfaccess
  .ashx?ResourceID8182188PDFSource13