AnticoagulationACCP guidelines 2012

Megan Chan, PGY-2UHCMC

CoumadinO Inhibits the cyclic interconversion of Vit K

in the liver decrease activation of factors 2,5,9,10

O During 1st 2-3 days of initiation, can be hypercoagulable 2/2 coumadin’s effects on Protein C & S

O Typically 5mg dailyO If outpt can do 10mg x2 day loading doseO Lower dose in elderly, liver dz, poor

nutritional status, HF

INR monitoring as Outpatient

O 1st check is after 2-3 dosesO Then 2x/wk until INR therapeuticO Then weeklyO Then every other week then monthlyO Then q3 months if has had 3 months

of consistent resultsO If INR not in desired range can

increase or decrease by 5-20% of total weekly dose

http://www.aafp.org/afp/2013/0415/p556.pdf

Unfractionated Heparin

O Works by binding to antithrombin to inactivate thrombin (Factor IIa) and Factor Xa

O Also prevents growth and potential propagation of clots

O Half life: 30mins to 2 hoursO Risk of HIT:

O Plts decrease by >50% or are <150K after initiation of heparin

O Usually 5-14 days after initation

LMWHO Enoxaparin (Lovenox), Dalteparin

(Fragmin)O Increased affinity to Factor Xa

relative to thrombinO Therapeutic dosing 1mg/kg q12 hrs

or 1.5mg/kg once a dayO Avoid in pts with CrCl <30 mL/min

and in pts with HITO Half life: 3-6 hours

Fondaparinux (Arixtra)O Specific only to Factor Xa thus low

risk for HITO Recommended for general surgery

prophylaxis in pt’s have contraindications to LMWH

O SubQ injectionO Half life: 18 hours

Bivalirudin (Angiox)O Reversible direct thrombin

inhibitorO Used here at UH for pts you suspect

or have HITO Continuous Drip

Dabigatran (Pradaxa)O Direct thrombin inhibitorO PO med FDA approved in 2010O Can be used for Afib

stroke/embolism preventionO 150mg BID, adjust for decreased CrCl

O Pros: no monitoring or overlap needed, fewer drug/food interactions

O Cons: Short half-life (12-17 hrs), no antidote for reversal

Rivaroxaban (Xeralto)O Direct factor Xa inhibitorO PO med FDA approved 2011O Indications:

O Tx of DVT/PE & reduce risk of recurrenceO DVT prevention in knee/hip replacement

surgeryO Dosing:

O DVT prophylaxis: 10mg dailyO Tx DVT or PE: 15mg BID x 21 days then 20mg daily O Afib: 20 mg dailyO Adjust for lower CrCl

O Half life 5-9 hours

Apixaban (Eliquis)O Factor Xa inhibitorO PO med FDA approved in 2012O Indicated for Afib related stroke

or embolism preventionO Dosing:

O Typically 5mg BIDO lower for elderly, low body weight,

CKDO Half life 12 hrs

  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 <2.0

Stop warfarin and start rivaroxaban once INR <3.0

Stop warfarin and start apixaban once INR <2.0

Stop warfarin and start apixaban once INR <2.5

Credits: Sarah Dickey, Pharm DLouis Stokes Cleveland VAMC

VTEO Tx initiation: Coumadin +

Heparin/FondaparinuxO At least 5 days overlap and until pt’s INR is

at least 2.0 for 2 consecutive daysO Rivaroxaban approved for tx of DVT or

PEO LMWH best for anticoagulation in those

with solid tumor-related VTEO ½ the risk for recurrent VTE than

Coumadin in those with malignancy-related VTE, no effect on mortality

Treatment course for VTEO 1st provoked DVT or PE: 3 monthsO 1st unprovoked DVT or PE:

O 3-6 months if low risk for bleeding, then evaluate risk-benefit ratio for extended therapy.

O 3 months if high risk for bleedingO 1st VTE = unprovoked PE:

O Life long if low risk bleedingO 3 months if high risk for bleeding

O 2nd unprovoked DVT or PE: O Life-long if low-moderate risk bleedingO 3 months if high risk bleeding

O Recurrent: lifelong therapyO PE with active cancer: life long therapy O Catheter related: 3 months after catheter removed

Non-valvular AfibO CHA2DS2VASC:

O CHF, HTN, Age 65-74 =1 vs ≥75 =2, DM, Stroke/TIA, Vascular dz

O Coumadin, Dabigatran (Pradaxa) & Apixaban (Eliquis) O Afib + Stable CAD (no ACS in past year)—coumadin

alone > coumadin + ASAO Intermediate-High risk Afib with ACS –anticoagulant

+ single antiplatelet for 12 monthsO Low risk Afib with ACS—dual antiplatelet therapyO High risk Afib with stent placement—triple therapy

(anticoagulant, ASA, plavix) for at least 1 month of bare metal, 3-6 months for drug-eluting anticoagulant + single antiplatelet

O Low-Intermediate risk Afib with stent placement—dual antiplatelet therapy > triple therapy for 12 months

CardioversionO If Afib/Aflutter >48 hrs or unknown

duration, anticoagulate for 3 weeks prior & 4 weeks post cardioversion

Prosthetic valvesO INR goals:

O Mechanical aortic valve: 2.0-3.0 + ASA

O Mechanical mitral valve: 2.5-3.5 + ASA

O Mechanical aortic + mitral valve: 2.5-3.5 + ASA

Hx of Noncardioembolic Ischemic Stroke or TIA

O Plavix 75mg daily ORO ASA/ER dipyridamole

25mg/200mg BID ORO ASA (75-100mg daily)O Cilostazole 100mg BID

Stroke/TIA + Afib:O Dabigatran 150mg BID > Coumadin

> ASA + PlavixO Often bridge

Pre-Op/Post-OpO Warfarin should be stopped 5 days

before major surgery and restarted 12-24 hrs post-opO Can bridge with LMW heparin for pts

with high risk of thromboembolismO Restart LMWH 24 hrs after

CABGO Continue ASAO Stop plavix 4 days before surgeryO 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.

ReferencesO http://www.aafp.org/afp/2013/0415/p556.ht

mlO http://journal.publications.chestnet.org/pdfa

ccess.ashx?ResourceID=8182188&PDFSource=13